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LIBRARY OF CONGRESS. 



"UNITED STATES OF AMERICA. j 




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PERCUSSION 



AND 



AUSCULTATION. 



Percussion and Auscultation 

AS DIAGNOSTIC AIDS. 



A MANUAL FOR STUDENTS AND PRACTITIONERS 
OF MEDICINE. 



BY 

DR. CARL HOPPE, 

ASSISTANT PHYSICIAN TO THE SIXTH WESTPHALIAN REGIMENT OF 
INFANTRY. 



TKANSLATED BY L. C. LANE, M.D. 




PHILADELPHIA I 

J. B. LIPPINCOTT & CO 
1869. 






Entered according to Act of Congress, in the year 1869, by 

J. B. LIPPINCOTT & CO., 

In the Clerk's Office of the District Court of the United States for the Eastern 
District of Pennsylvania. 



TEAKSLATOE'S PEEFAOE. 



No studied preface is needed in recommendation of 
the following work ; an examination of its pages, even 
cursorily, will convince the practitioner as well as the 
student of medicine that, though a compend, it con- 
tains far more than many of the large works on the 
same subject, — being, in fact, a master-piece in both 
thoroughness and brevity. 

San Francisco, June 29, 1869. 



(5) 



PEEFACE. 



It cannot be denied that auscultation and percussion 
have long failed to serve their proper purpose. Per- 
haps the chief cause of this is want of leisure, among 
the more busy of our physicians, to study comprehen- 
sive works on this subject. The scarcity of shorter 
works of this kind has induced me to undertake the 
following, which will give, in a condensed form, the 
views of Scoda, Piorry, Traube, Wintrich, and Bam- 
berger on percussion and on auscultation. The views 
and teachings of Traube, so highly esteemed by myself 
and others, will receive especial attention. 

Without long theoretical explanations, I wish to pre- 
sent only what is useful and necessary for practical 
purposes, especially for diagnosis. I thus hope through 
this little book to make the acquisition of auscultation 
and percussion easier to the student, and also, now and 

m 



8 PREFACE. 

then, to win to the study a physician who shrinks from 
so great a labor. If by this means I succeed in ren- 
dering assistance in the diagnosis of diseases of the 
heart and lungs, my feeble powers will be rewarded 
for their labor. 

Dr. Carl Hoppe. 
Minden, April, 1865. 



PERCUSSION. 



PEKCUSSIOK 



The former method of percussion was imme- 
diate, the modern method is mediate. Laennec 
percussed directly upon the surface of the body, 
with the ends of the fingers bent and pressed 
together ; at the present time one finger of the 
left hand is placed upon the body, and receives 
the percussion made with the ends of one or 
two fingers of the right hand. In mediate per- 
cussion the percussing hammer and pleximeter 
are used. By means of percussion not only the 
sound, but also the resistance of the part of the 
body can be tested. The percussion by palpa- 
tion, introduced by Piorry, includes both meth- 
ods. The latter can be performed either with 
the fingers or with the percussing hammer. The 
best way is to percuss on the surface of the plex- 
imeter in a sort of iambic measure, rather press- 
ing and thrusting than striking. Percussion by 
palpation is particularly adapted to determining 
the boundaries of an organ. 

In order to be able to determine the range of 

en) 



12 PERCUSSION. 

sound, let one imagine the following lines drawn 
on the anterior wall of the thorax : — First, the 
linea sternalis, along each side of the margin of 
the- sternum; second, the linea mammillaris, 
through the papilla mammalis, or nipple, par- 
allel to the first; third, between these two the 
linea parasternalis. Besides these, the supra- 
and infra-clavicular regions are to be distin- 
guished. On the lateral wall draw the linea 
axillaris perpendicularly through the axilla. On 
the posterior wall may be marked off the supra- 
and infra-spinous regions, and the inter-scapular 
and infra-scapular regions. On the abdomen the 
regions may be designated either according to 
the organs within (as the hepatic and splenic 
regions), or according to the commonly accepted 
anatomical regions. 

Various opinions exist in regard to the origin 
of the sound produced by percussion. Some 
maintain that the sound is caused by the vibra- 
tion of the thoracic wall, which presents a curved 
elastic surface. This theory is refuted' by the 
following experiment: — If we place the plexim- 
eter on the infra- clavicular region of a cadaver, 
and then place a heavy weight around it, in the 
form of a half-circle, exactly the same sound can 
be produced before and after the pressure, even 
when the thorax is strongly compressed. But 
with metal plates a heavy pressure makes the 
sound weaker and higher. 



PERCUSSION. 13 

Scoda and his followers were of the opinion 
that the sound arises from the vibration of the 
air within the thorax; and according to a third 
view, the lungs vibrate and create the sound by 
virtue of the different degrees of tension of their 
membraneous elements. For the last two theo- 
ries convincing arguments are wanting, and yet 
one or the other, or the two combined, must be 
correct. 

The sound of percussion over the stomach, in- 
testines, and lungs, when removed from the body, 
is loud, high, and tympanitic. The tympanitic 
sound is the same as that produced in a tube of 
any material by the vibration of the air within 
it. This sound can be very distinctly heard by 
placing the pleximeter tightly over a tolerably 
high empty glass, and rapping upon it with the 
percussing hammer of .the pleximeter. If the 
percussion be made near the glass, the sound is 
not tympanitic. A relaxed stomach gives a high 
but yet tympanitic sound, varying according to 
the degree of inflation. If wholly inflated, the 
tympanitic sound disappears. This phenomenon 
is explained in the following manner : On the 
relaxed stomach one can only hear the tympa- 
nitic sound of the air, because loose membranes 
can produce no sound. 

After the inflation the walls are tense, and 
themselves produce a sound. But tense mem- 
branes are bad conductors of the vibrations of 

9* 



14 PERCUSSION. 

air; they offer great resistance; and consequently 
only the sound of the membrane is heard, sur- 
passing the tympanitic sound of the air. The 
lungs, when removed from the body, also give a 
tympanitic sound; but in their normal condition, 
within the thorax, they do not. This phenome- 
non may be explained in the same way as the 
preceding. The lungs, removed from the body, 
contract and lose their tension which they had 
within the thorax, therefore the tympanitic sound 
is in them, and not in the thorax. The sound 
produced by percussion is a mingled tone. A 
mingled sound results from two vibrating bodies, 
but each of these bodies produces, when per- 
cussed alone by itself, another sound, differing 
from that of the percussion. The intestines, the 
lungs, and the air, each gives an individual sound; 
the mingled tone is produced from the two vi- 
brations combined. The two extremes of this 
mingled sound can be heard when one of them 
overcomes and surpasses the other. This occurs 
in the stomach according as it is relaxed or dis- 
tended, and in the lungs as they are removed 
from the cavity of the thorax or within it. The 
pathological facts which support these theories 
will be mentioned under the head of " Tympa- 
nitic Sounds." 



PERCUSSION. 15 

Phenomena peculiar to the Sound produced by Per- 
Hussion. 

The sound may vary in the following particu- 
lars: 

(1) According to its intensity; that is, dull and 
loud. On the right side, beneath the sixth rib, 
it is far less loud than in the infra-clavicular 



region. 



(2) According to its highness, or acuteness. 
Under this head it may be classed as deep and 
high. In the lower part of the left side of the 
breast the sound is higher than under the clavi- 
cle, and in the abdomen it is higher than in the 
thorax. 

(3) According to its quality, or timbre. It 
may have a ringing sound, either tympanitic or 
metallic, or a non-resonant sound. The sound 
is tympanitic upon the abdomen, and metallic in 
case of pneumothorax. 

(4) According to its duration. In this respect 
metal and wooden plates differ much, but in the 
body this difference, when perceptible, is very 
slight. It is best, therefore, not to take this 
property of the sound into consideration. Scoda 
makes still another distinguishing condition, 
viz., the full and the empty tone. A large bell 
may give the same tone as a smaller bell, but it 
will be fuller. The idea of fullness and empti- 



16 PERCUSSION. 

ness of tone comprehends two conditions, viz., the 
pitch and duration of the sound, but it does not 
constitute a peculiar acoustic condition. Scoda 
himself intends to express depth and height of 
tone by the terms full and empty. 

The absolutely deadened, dull sound of per- 
cussion can be illustrated, according to Scoda, by 
percussion on the thigh. All the fleshy, non-air- 
containing organic parts, with the exception of 
the ligaments and membranes when tense, give 
this sound. The sound produced by percussion 
over the heart, liver, spleen, or over a hepatizecl, 
compressed lung from which the air has been 
expelled, is not absolutely but only relatively 
deadened, because, at the same time with these 
parts, neighboring air-containing organs are 
thereby thrown into vibration. 



CHAPTEE I. 

INTENSITY OF THE PERCUSSION SOUND. 

Various conditions can influence the strength 
of the sound. 

(1) The sound becomes deadened by every 
considerable thickening of the softer parts of the 
muscles, as well as of the skin. The sound is 
produced in the thorax, and is transmitted 
through its walls to the ear. A part of the force 
of the percussion is thus lost, — that is, so much 
as is dissipated by the molecular displacement of 
the softer parts. The thicker the latter are, the 
greater the loss of force. On the posterior chest- 
w^all, especially on the scapulae, the sound is 
duller than farther forward, because the layer of 
muscles is thicker here. A thick stratum of 
adipose tissue, oedema of the skin, likewise 
deadens the sound. 

(2) The tension of the softer parts has also an 
influence on the strength of the sound. If the 
head be raised and the abdomen be percussed in 
the region of the musculi recti, which thus be- 
come tense, a considerable deadening of the 
sound is observed. 

(H) 



18 INTENSITY OF THE 

(3) The degree to which the thoracic wall 
yields, also determines the strength of the sound. 
In muscular persons, whose ribs yield but little, 
the sound is somewhat muffled. It is less dull 
over the intercostal spaces than over the ribs, 
and the wider the former are, the louder is the 
sound. For the same reason the thorax of 
children usually gives a louder sound. 

(4) The more convex the walls of the thorax, 
the less are they adapted to receive and trans- 
mit the sound. In old people the clavicles 
often project very much, and this deadens the 
sound somewhat. In persons with posterior 
spinal curvature the sound becomes deadened on 
the projecting side. 

(5) Those organs which contain little or no air 
deaden the sound of the percussion. Thus, it is 
deadened over the liver, heart, spleen, kidneys, 
and impregnated uterus ; over a full stomach, a 
distended bladder, or over the rectum filled with 
feces. In normal defecation the left iliac region 
gives a deadened, high, indistinct, or uncertain 
t3mipanitic sound ; but at the same time the right 
iliac region gives a loud, deep, distinctly tym- 
panitic sound; in diarrhoea these phenomena 
are usually reversed. 

(6) When the parenchyma of the lungs is void 
of air, or when the pleural cavity is filled with 
fluids the sound becomes deadened. Pneumonic 
or tubercular infiltration (the former most fre- 



PERCUSSION SOUND. 19 

quently behind and below, the latter above and 
in front) usually deadens the sound, if it (the in- 
filtration) is not too circumscribed, or does not 
lie too deep. Neither miliary tubercles nor 
small infiltrated spots can be detected by per- 
cussion. Miliary tubercles only give a dead- 
ened sound when very numerous and confluent, 
so that the parenchyma of the lungs can con- 
tain but little air. This deadening of sound 
is usually apparent only over the apex of the 
lungs ; and, as a rule, acute miliary tubercles are 
not recognizable by means of percussion. Dif- 
fused cancerous degeneration of the lungs, which 
lie near the thoracic wall, produces the same 
deadening of sound. Serous, purulent, or bloody 
effusions into the pleural cavities, likewise deaden 
the sound ; but a moderate effusion produces a 
perceptible deadening only when those parts of 
the lungs directly underneath have been rendered 
void of air by pressure on their circumference ; 
otherwise the sound is tympanitic and scarcely 
deadened. A moderate quantity of mucus in 
the bronchi, or air-cells, causes no perceptible 
deadening of the sound. 

(7) The intensity of the sound is inversely 
proportional to the degree of tension of the pa- 
renchyma of the lungs. If percussion is made 
during a paroxysm of coughing, which is pro- 
duced by a deep inspiration through the con- 
tracted glottis, the sound of the parenchyma of 



20 PECULIAR PHENOMENA OF 

the lungs, which has a greater degree of tension 
from the compression of air within, is deadened, 
and at the same time is rendered higher and non- 
tympanitic, when in natural, unobstructed respi- 
ration it was tympanitic. The sound in moderate 
pleuritic exudation is often loud, deep, and tym- 
panitic, because the lungs are compressed and 
their tension is diminished. In case of a great de- 
gree of tension of the membrane, its sound over- 
comes that of the air, and the sound of the former 
alone is heard ; in a diminished degree of ten- 
sion, the sound of the air becomes perceptible ; 
hence the loud and tympanitic sound. 

(8) The more extensive the vibrating mass, 
the louder the sound, and vice versa. In pneumo- 
thorax, where all the gas in the pleural cavities 
vibrates, the sound is thereby rendered very loud. 
When collapse of the lung-substance occurs in 
consequence of compression from exudation or 
induration of tissue, the sound becomes higher 
and duller. In a normal condition a percep- 
tible deadening commences under the fourth 
right rib, and this increases downward on ac- 
count of the lung-structure, which lies between 
the liver and the thoracic wall, gradually dimin- 
ishing in thickness. Cardiac dullness, although 
slight, may yet be perceived at the right of the 
median line of the sternum, and a quarter of an 
inch beyond the right sternal margin, on account 
of a thin layer of lung-substance lying over the 
right auricle. 



THE PERCUSSION SOUND. 21 

By the difference between tlie loud and the 
deadened sound we are enabled to define the 
topographical extent of the organs of the breast 
and abdomen. For all those organs which re- 
ceive no air, such as the liver, heart, and spleen, 
deaden the sound, but not in such a way as if 
each possessed an individual sound of its- own. 
We cannot speak of hepatic, cardiac, or splenic 
sound. 

The space occupied by the lungs is on an aver- 
age as follows: The apices extend above the 
clavicles, and they can be percussed over the 
fossa supra-clavicularis, close to the origin of the 
sterno-cleido-mastoid muscle. The right lung 
reaches in the linea parasternals as far as the 
union of the sternum with the xiphoid process, 
where the anterior edge curves outward into 
the lower margin ; in the linea mammillaris it 
reaches as far as the upper edge of the sixth rib, 
in the linea axillaris to the eighth rib, and behind 
as low as the eleventh rib. The two acute ante- 
rior edges of the lungs reach behind the manu- 
brium of the sternum, converging toward each 
other. They are separated from each other, on 
a level with the second costal cartilage, by the 
mediastinum only, of which the two laminae are 
here united. Thus close to each other they run 
slightly to the left of the median line as far as 
the fourth costal cartilage ; in like manner the 
mediastinum is disposed. At this point the latter, 

3 



22 PECULIAR PHENOMENA OF 

as well as the former, begins to diverge, the right 
anterior edge of the lung deviates a little from 
the middle line toward the right, but not so far 
as the right edge of the sternum, and turns back- 
ward below the sternal edge of the sixth rib into 
its inferior margin. The anterior edge of the left 
lung extends from the fourth rib to the left edge 
of the sternum, and onward as far as the outer- 
most third of the sixth costal cartilage (present- 
ing outwardly a slightly convex surface), where 
it merges into the inferior margin. The lungs 
also completely cover the heart and pericardium 
as far as the upper part of the fourth rib, and to 
that point they are lined with the laminae of the 
mediastinum. But from the fourth to the sixth 
rib, and from the median line to the left linea 
parasternalis, the heart is not covered by the 
lungs and mediastinum (where we have superfi- 
cial cardiac dullness), and here, between the peri- 
cardium and thoracic wall, we find connective 
tissue, so that at this place the pericardium can 
be punctured without injury to the pleura. In 
the linea mammillaris the left lung extends to the 
sixth rib, and in the linea axillaris as far as the 
sixth intercostal space backward to the eleventh 
rib. The study of the strength of the sound 
elicited by percussion is essential to the defining 
of the anterior edges of the lungs in the relation 
which they bear to the heart ; and the same is the 
case with the inferior and posterior edges of the 



THE PERCUSSION SOUND. 23 

lungs. Especially can wc judge of the mobility 
of the latter by the relations to each other of 
these sounds elicited by percussion during inspi- 
ration and expiration; in inspiration the dullness 
first commences at the right of the linea mam- 
millaris under the seventh rib ; on the thoracic 
wall in inspiration a louder, deeper, non-tympa- 
nitic sound begins to be perceptible between the 
sixth and seventh ribs. Adhesions of the pulmo- 
nary edges can likewise be perceived posteriorly 
below the eleventh rib. 

The position of the heart can be decided by per- 
cussion according to three methods. The first 
method is that of Piorry. By means of it we 
can define the limits of the complete anterior 
convex surface of the heart. This is accom- 
plished by means of palpatory percussion, in 
which hearing and feeling are both brought into 
service. The more flexible the ribs, and the 
thinner the stratum of lungs covering the heart, 
the more precise is the result obtained. Over the 
anterior wall of the thorax is a space, triangular 
in form, with its sides somewhat curved, where 
the deadening of the sound is heard. The upper 
angle lies at the union of the third left costal 
cartilage with the sternum. It cannot usually 
extend above the upper edge of the third rib, 
nor below the fourth rib. The right point lies 
over the sixth rib, and reaches from one-quarter 
to half an inch beyond the edge of the sternum, 



24 INTENSITY OF 

usually not more than half an inch. The left 
angle corresponds to the point of the apex-im- 
pulse, and lies a little within the linea mammil- 
laris. It cannot usually extend outside of the 
linea mammillaris. 

(2) The method of Conradi determines the so- 
called cardiac vacuum, or area of cardiac dull- 
ness, — that is, the part of the heart which lies be- 
tween the anterior edges of the lungs and is not 
covered by pulmonary structure. During expi- 
ration the anterior edges of the lungs are drawn 
backward, and leave a greater portion of the 
heart free than during inspiration. No doubt 
this circumstance renders the method unreliable. 
To establish a correct supposition, one must take 
as groundwork the fact that the lungs, when they 
extend beyond their natural limits, continually 
tend to contract, and that the more the heart ex- 
pands, the more they must yield. But when 
hypertrophy of the heart exists at the same time 
with expansion of the lungs, from emphysema 
resulting from chronic catarrh, then the super- 
ficial cardiac dullness may, as a rule, entirely or 
almost entirely disappear. In such cases this 
method is wholly unreliable. The area of car- 
diac dullness, determined by slight superficial 
percussion, is likewise a triangular space. The 
base coincides with that of the aforesaid larger 
triangle, but the upper angle lies in the fourth 
intercostal space on the left of the sternum ; the 



THE PERCUSSION SOUND. 25 

right point in the median line at the upper end 
of the xiphoid process ; the left angle nearly cor- 
responds with the point of cardiac impulse, or 
lies a little farther to the left. 

(3) The method of the Vienna school, the easi- 
est for beginners, does not take into account the 
condition of the position of the heart, and only 
decides whether the muffling of sound, which is 
perceived by means of strong percussion in a 
large number of healthy individuals, is heard 
or is absent in the case in question. This dull- 
ness of sound begins at the fourth rib, and, con- 
tinually increasing, extends to the inferior edge 
of the fifth or sixth rib. The lateral boundaries 
of this dullness also increase from above down- 
ward, being greatest in the intercostal space 
where the apex-impulse is perceived. There it 
extends to the right as far as the inferior part of 
the sternum, but at that point is less intense 
than at the left of the sternum. 

The method of Piorry is the only one which 
enables us to decide exactly by means of percus- 
sion the position, form, and diameter of the heart. 
The dullness perceived by the two other methods 
may also be produced by solidification of lung 
structure, or by other causes ; the heart need not 
necessarily be the seat of the muffled sound. 
Auscultation, palpation, and the apex-impulse 
must then aid the diagnosis. The following 

3* 



26 PECULIAR PHENOMENA OF 

facts are, however, established by percussion 
over the heart : 

(1) If the muffling extends perceptibly beyond 
the linea mammillaris, toward the left, and the 
other boundaries retain their normal condition, 
so that thus a malposition of the heart through 
pleuritic exudation would be impossible, we may 
assume that there is enlargement of the left ven- 
tricle, but we must be sure that the muffling of 
sound proceeds from the heart. 

(2) If the dullness of the sound extends more 
than half an inch beyond the right edge of the 
sternum, and this deadening comes necessarily 
from the heart, it is an indication of enlarge- 
ment of the right ventricle. 

(3) Evident increase of the area of cardiac 
dullness, and especially augmentation of the 
same upward, are essential symptoms of peri- 
cardial exudation or transudation. But other 
signs must confirm this opinion, viz., a complete 
or partial disappearance of the apex-impulse and 
pericardial friction-sound. 

A diminution of cardiac dullness occurs when 
the edges of the lungs extend farther over the 
anterior surface of the heart, in which case the 
lungs may be either in a normal or an emphyse- 
matous condition. 

Percussion of the Liver. — The right lung, of 
which the lower edge extends obliquely into the 
space between the thoracic wall and the dia- 



THE PERCUSSION SOUND. 27 

phragm, which extends upward and inward, 
covers the upper part of the liver in such a 
manner that there is a layer of lung-substance, 
constantly decreasing in thickness, lying between 
the liver and the walls of the chest. The lower 
part of the liver is in close proximity to the 
thoracic wall. The highest point of the convex 
surface of the liver falls on a level with the 
fourth rib. The lower edge falls forward in the 
right hypochondrium, under the arch of the ribs, 
as far as the end of the tenth rib. From here it 
may be traced obliquely through the epigastrium 
into the space between the umbilicus and xiphoid 
process, toward the left hypochondrium. Percus- 
sion by palpation is best adapted to examination 
of the liver ; the percussion must be strong on 
the upper part covered by the lungs, but less so 
for the determination of its lower boundaries. 
Since the position of the liver varies, the dimen- 
sions of the same must constantly be taken into 
account. In the linea axillaris its upper edge 
commences at the sixth or seventh rib, its diame- 
ter there being four inches; in the linea mammil- 
laris its upper edge begins in the fourth inter- 
costal space, at the fifth rib, or in the fifth 
intercostal space, having a diameter there of five 
inches. In the median line the determination of 
the same is unreliable, because a portion of the 
liver lies concealed beneath the heart, so that 
sometimes only one-half, or even less, of it can 



28 PECULIAR PHENOMENA OF 

defined. The part which can be measured equals 
3 inches in extent. The left lobe, projecting 
beyond the linea alba, is from 2J to 2| inches in 
breadth. The lower edge reaches to the costal 
arch or somewhat beyond. In percussion on this 
edge one can easily be deceived, if an intestinal 
fold lies between the lower part of the liver and 
the thoracic wall, as is especially the case in 
meteorism. The lower edge then appears to lie 
higher and the liver to be diminished in size. 
By repeated percussion the error is perceived. 

The spleen lies about parallel with the tenth rib 
and ninth intercostal space, extending forward, 
outward, and downward. In practice it is enough 
to define the forward apex and its breadth in the 
linea axillaris, which is about 5 centimetres, or 
nearly two inches. The region of splenic dull- 
ness is limited behind by the eleventh dorsal ver- 
tebra, downward by the eleventh rib, upward 
toward the axilla by the ninth rib, and forward 
by an imaginary line drawn from the apex of the 
eleventh rib to the papilla mammalis, or nipple. 
If the spleen does not project forward over this 
line, we can assume that it is not enlarged. 
The spleen can usually be sounded by palpation. 
The fingers of the left hand can be made to 
extend tolerably high under the ribs during 
expiration by the patient, particularly if he is 
emaciated or thin. In deep inspiration the spleen 
can be felt as a solid body pressing against the 



THE PERCUSSION SOUND. 29 

ends of the fingers. The normal spleen cannot 
be felt in this way. If fastened by adhesions, it 
does not move downward in inspiration nor by 
its own weight ; while, on the other hand, the 
spleen that has been enlarged for a long time 
sinks downward: then the upper limit of the 
enlargement can easily be defined by percussion. 
The spleen is enormously enlarged in leucaemia, 
and its anterior surface then usually presents a 
series of deep indentations. The abnormally 
loud sound appears under the same conditions 
as the tympanitic, of which hereafter. Yet air- 
containing cavities, which are adapted by their 
size and superficial position to the production of 
a tympanitic sound, now and then give a non- 
tympanitic, but abnormally loud, sound. Then 
there are conditions present which prevent the 
occurrence of the tympanitic sound, viz., either 
the free communication of the atmospheric air 
with the hollow cavity is suspended by obstruc- 
tion of a bronchus, or other cause, or the walls 
of such cavity may be too tense. This may 
occur in the tubercular cavern, bronchial dilata- 
tion, and pneumothorax. 



CHAPTER II. 



HEIGHT OF THE SOUND. 



There are fewer conditions or qualifications in 
the height of the sound than in its intensity. 

(1) The smaller the vibrating mass that is the 
volume of the air-containing parenchyma, the 
higher is the sound; the greater the mass, the 
deeper the sound. A part of a lung gives a 
much higher sound than a whole lung. If, in 
case of extensive pleuritic exudation, the apex 
only of the upper air-containing lobe can still 
vibrate, then the sound over it is muffled, non- 
tympanitic, and higher than on the other side. 
Small, superficially situated air-containing parts 
of the lung, which are found in the midst of the 
parenchyma emptied of air, also give a muffled, 
high sound. Over thin layers of lung-substance, 
under which lie non-air-containing organs, like 
the liver and heart, the sound is likewise dead- 
ened and higher. 

Scoda considered the only cause of his full and 

empty, deep and high sounds, to be the volume 

of air contained in the thorax. "Wintrich has 

shown that there is still another condition, viz., 

(30) 



HEIGHT OF THE SOUND. 31 

(2) The degree of tension of the parenchyma 
of the lungs, or of the walls containing the air. 
The greater this tension, the higher is the 
sound; the less the tension, the deeper is the 
sound. When the walls vary in size but have 
the same tension, the smaller has a higher sound 
than the larger. For example, he adduces : let 
the healthiest person after deep inspiration cough 
strongly, with the glottis closely contracted, and 
percussion meanwhile be made, we shall be 
astonished to hear how much more muffled, 
shorter, weaker, and higher the non-tympanitic 
sound appears in those parts of lung-structure 
thereby greatly compressed in comparison with 
that heard in undisturbed respiration. He proved 
this by placing weights upon a portion of lung, 
and thus producing different degrees of tension. 
This condition also admits of pathological proof. 
In pleuritic exudation the muffling of the sound 
begins behind and below, and reaches higher 
there than hi front, which circumstance is the 
result of the horizontal position of the patient. 
The lower parts contain no air, the upper parts 
but little. In this condition the sound from be- 
low the clavicle of the affected side, which was 
at first loud, deep, and tympanitic, is rendered 
dull in a downward and lateral direction. The 
question arises, Whence this depth of sound ? On 
the affected side the volume and tension of the 
lung have decreased. Diminution of the volume 



32 HEIGHT OF THE SOUND. 

increases the height of the sound, diminution of 
tension increases the depth of the sound. Since 
it is deeper now, the diminution in tension must 
be the greater. The longer the sound-wave, 
the deeper the note produced. The longer 
the sound-wave, the less frequently are its vi- 
brations repeated in a second, and consequently 
the smaller is the number of vibrations. The 
number of vibrations, or the height of the sound, 
is equal to the tension divided by the volume, or 
h = |. If the diminution in volume is greater 
than the diminution in tension, the sound be- 
comes higher. This finally occurs where the ex- 
udation increases. Then the sound underneath 
the clavicle of the affected side is higher. The 
same is true in pneumonia. In the later stages 
of pneumonia, since it is usually located behind 
and below, the larger posterior part of one lobe 
becomes hepatized, but only the smaller anterior 
part; anteriorly, the greater part is still air-con- 
taining. We hear, then, over the affected lobe, 
anteriorly, a loud, high, tympanitic sound. The 
air-cells, posteriorly, become distended by fibrin- 
ous exudation, and so cause, anteriorly, through 
compression, diminution of volume and decrease 
of tension. The former surpasses the latter, 
therefore the sound is higher. In the earlier 
stages of pneumonia, when the exudation is not 
yet so abundant, the diminution of tension is in 
excess of the diminution of volume. Hence in 



HEIGHT OF THE SOUND. 33 

this stage the sound is deep. The dependence 
of the height of the sotfnd upon the degree of 
tension also shows itself in dry catarrh. In deep 
inspiration the sound is also higher than in expi- 
ration. In inspiration the volume as well as the 
tension is increased. By the increase in volume 
the sound ought to become deepened; but, since 
it becomes higher, the increase of tension must 
be greater. 

From the two named conditions of the height 
of the sound we deduce the following diagnostic 
aids : 

(1) It cannot be decided with certainty that 
there is increase in size because there is deepen- 
ing of sound ; there may even be diminution in 
size. 

(2) It can be decided with certainty that there 
is diminution in size, if the high sound remains 
constant and is at the same time muffled. This 
is the case in tuberculosis. 

(3) Further, the height of the sound depends 
upon the length of the vibrating column of air. 
The longer the column of air, the deeper is the 
sound; the shorter it is, the higher is the sound. 
Therefore, in pneumothorax the sound on the 
affected side is tympanitic and deep, and the 
deeper it is the more extensive is the pneumo- 
thorax. 

(4) The greater the opening of the sounding 
space, the higher is the sound. When we 

4 



34 HEIGHT OF THE SOUND. 

percuss a column of air in a vessel, the greater 
the opening it may Save, the higher is the 
sound produced. If orifices are made in the 
vessel, the tympanitic sound becomes higher. 
( Wintrich.) In case of tuberculous caverns the 
sound becomes much higher if the patient holds 
his mouth open during percussion. By means 
of the trachea and glottis the caverns are in free 
communication with the opening of the mouth ; 
the opening of the mouth is also, to a certain 
degree, the outlet of the same. Wintrich diag- 
nosticated caverns from this circumstance, but 
yet he himself cites cases in which the tympanitic 
sound is sometimes high and sometimes deep. 
"When the superior anterior part of the lung is 
completely hepatized, or when the lung-tissue 
becomes strongly compressed by a pleuritic ex- 
udation situated anteriorly around the apex of 
the lung, the trachea is in the exact condition 
of a cavern, since the lung-tissue no longer con- 
trols the sound ; but probably it propagates the 
shock of the percussion. He says, further, that 
this difference manifests itself even in the ex- 
tremely rare case when a circumscribed pneumo- 
thorax stands in connection with the trachea 
and oral cavity by means of a large fistulous 
orifice. 



CHAPTER III. 

THE TIMBRE OR QUALITY OF THE SOUND. 

A. The Tympanitic Timbre. 

The tympanitic timbre may be distinguished 
by means of a ringing sound, which, approaches 
to, or resembles, a musical tone. The difference 
between intensity and highness is most readily 
to be distinguished in this sound. This tym- 
panitic sound may be represented by holding the 
pleximeter over a tube filled with air and per- 
cussing upon it with the percussing hammer. 
Scoda found that a distended stomach gives a 
tympanitic sound when its walls have a slight 
degree of tension, but that this timbre disap- 
pears in proportion as the tension of the walls 
is increased by inflation. He maintained that 
the percussion sound is, without exception, tym- 
panitic if the walls which inclose the air are not 
tense; but in increased tension of these walls 
the percussion sound appears less or not at all 
ty mpanitic, and also more dull. Thus, when the 
tympanitic sound can be heard on the thorax, we 
can infer that the tension of the parenchyma is 
lessened. In a normal condition the tympanitic 

(35) 



36 THE TIMBRE OR QUALITY 

sound can be heard in the crescentic space of the 
thorax (of which hereafter), and on the abdomen 
over the stomach and intestinal canal, so long as 
the gas within the walls does not make them too 
tense. If over this part the tympanitic sound 
cannot be heard, there must exist an abnormal 
condition. There is then either a great tension 
of the walls, on account of gaseous contents, as 
in meteorism, or there is fluid in the abdomen, 
or the stomach and intestines are filled with fluid 
or solid matters. 

In an abnormal condition the tympanitic 
sound is heard on the thorax in the following 
cases : 

(1) In pleuritic exudation the sound below the 
clavicle of the affected side is loud, deep, and 
tympanitic. The diminution of tension, which, 
as cited in regard to height of sound, is the cause 
of the deepness of the sound, also produces the 
tympanitic timbre. 

(2) When in pneumonia the posterior part of 
the lower lobe is hepatized, a loud, deep, tym- 
panitic sound is heard, beginning anteriorly. 
Here, too, we find diminution of tension. The 
volume of hepatized lung becomes so enlarged 
by fibrinous exudation in the air-cells, that, for 
example, the upper lobe of the right lung, which, 
in its normal state, reaches only to the third in- 
tercostal space, when hepatized may be found 
reaching even to the sixth rib. Through this 



OF THE SOUND. 37 

enlargement of the posterior half the anterior part 
becomes compressed, and hence the parenchyma 
loses its tension. 

(3) Over hollow cavities and caverns, which 
contain air and are situated superficially, as in 
dilatation of the bronchial tubes, the tympanitic 
sound likewise appears; that is, the sound of the 
air contained within them, in case there be di- 
minished tension of their walls and of the sur- 
rounding parenchyma. In case this parenchyma 
is normally filled with air, the tympanitic timbre 
is absent. In tuberculous caverns the neighbor- 
ing tissue is generally infiltrated and void of air, 
therefore the tympanitic sound may usually be 
heard over them. Still, these caverns must be 
of a certain extent, which cannot be exactly 
computed. When small caverns of the size of a 
bean or hazel-nut exist in the apex, then the 
sound, in consequence of the infiltration of the 
surrounding tissue, frequently becomes muffled 
and non-tympanitic. If several small cavities 
lie near one another, then the non-tympanitic 
sound may be normally just as loud as on the 
healthy side, or even louder. In such cases the 
certainty of diagnosis is aided by auscultation. 

If the nose and the mouth of the patient be 
tightly closed, and at the same time the dia- 
phragm be caused to contract, the tension of the 
walls becomes much increased, and the tym- 
panitic sound over the caverns disappears. When 

4* 



38 THE TIMBRE OR QUALITY 

a mass of mucus, pus, or blood shuts off a 
cavern from a bronchus, this immediately causes 
an increased tension of the walls, which destroys 
the tympanitic sound. If the cavities are filled 
with mucus, or other substance, then of course 
the tympanitic sound disappears, but it returns 
again as soon as the fluids are removed by ex- 
pectoration. 

(4) In pneumothorax the tympanitic sound of 
the air is heard when the wall of the thorax has 
not too much tension. But if the intercostal 
spaces are closed by the pressure of air in the 
pleural cavity, the tympanitic sound disappears. 
In extensive distention of the abdomen from 
meteorism, for the same reason, that — is, from 
too great tension of the walls, — the previous 
tympanitic sound disappears. 

(5) In acute oedema of the lungs the tympa- 
nitic sound also occurs occasionally, even when 
the lung is emphysematous, because a diminution 
of the tension of the parenchyma is combined 
with the watery infiltration. 

Caverns and pneumothorax excepted, the tym- 
panitic sound leads us to the general conclusion 
that the tension of the parenchyma of the lungs 
is diminished. The cause of the diminution 
of tension or of the tympanitic sound, in any 
given case, can only be determined by the help 
of other physical symptoms. 



OF THE SOUND. 39 



B. The Metallic Timbre. 



The metallic sound can be heard very dis- 
tinctly in the percussion of empty vessels, either 
open or closed with a cover. That this sound 
differs from the tympanitic sound, may be proved 
by this, that a tensely distended bladder no longer 
gives the tympanitic sound, but it may give the 
metallic sound, which, a partially distended blad- 
der may also give. Wintrich was the' first to 
state the conditions of the metallic sound. (1) 
The walls of the sounding space must be so 
smooth that there may be a uniform reflection 
of sound from wall to wall. Still, an absolute 
smoothness of surface is not necessary. But ir- 
regular surfaces of unequal thicknesses prevent 
the formation of the metallic sound. (2) The 
greatest diameter of the sounding space cannot 
be less than about 1J inches. This is the prin- 
cipal reason that caverns do not emit the metallic 
or ringing sound. For the smaller the sound- 
ing space, the higher and weaker is the metallic 
sound ; for instance, in quite small elastic balls 
it is only perceptible when they are'held close to 
the ear. 

The reason that in pneumothorax the metallic 
sound is often heard only in percussion on certain 
spots, arises from the fact that only by percus- 
sion over these places can the column of air in its 
greatest diameter be set in motion. 



40 THE TIMBRE OR QUALITY 

When the walls are thick, the metallic sound 
produced within is not distinctly heard from 
without, and the sound is louder from unob- 
structed than from closed passages. 

In addition to this, Traube has discovered that 
the metallic sound is not heard when the tension 
of the. air becomes too great. In pneumotho- 
rax the metallic sound is always to be heard 
post-mortem ; but if the tension of the air in the 
thorax be made greater by the upward pressure 
of the diaphragm, this sound disappears. It is 
not in reality the air which destroys the metallic 
sound, but the tension of the soft parts, resulting 
from the presence of the air. This is also the 
reason that the metallic sound is heard on the 
cadaver, but, on the contrary, seldom on the living 
body. After death, the temperature being less- 
ened, the tension of the air and of the soft parts 
also becomes diminished. Hence it follows, too, 
that intercostal spaces, which in life were full, 
after death become depressed. 

On the living body the metallic sound is seldom 
heard, because usually one of the conditions 
named is not filled. It can be perceived: 

(1) In pneumothorax. But it is usually neces- 
sary during percussion to auscultate at the same 
time with the stethoscope ; first, because the 
cavity of the pneumothorax is usually closed, and 
also because the walls of the thorax are for the 
most part too thick to allow much of the sound 
produced within to pass through them. 



OF THE SOUND. 41 

(2) In case of caverns in the lungs. If these 
are closed, they cannot have a diameter of less than 
six centimetres, or about 2| inches, in order to 
produce the sound. Open caverns, that is, such 
as have free communication through a bronchus 
with the atmospheric air, still give the metallic 
sound even with a smaller diameter. 

Still, such communication is unfrequent; the 
bronchus often becomes obstructed, so that the 
metallic timbre can only appear temporarily. 
The presence of fluids in the caverns does not 
prevent the production of the metallic sound, 
nor, according to Piorry, are they necessary to 
it. Still, of course, the sounding space must not 
be too much diminished by the quantity of fluid. 
In the case of small caverns, the metallic sound 
can be better heard by bringing the ear close to 
the thorax (that is, in superficial caverns) or near 
the mouth of the patient. 

The height of the metallic sound, unlike that 
of the tympanitic, is not varied by opening and 
closing the mouth, but is always in proportion to 
the height of the vibrating column of air. The 
smaller this is, the higher is the sound. 

The Sound of a Cracked Kettle {Bruit de potfele). — 
The Sound of Clinking Coin. 

The term " Sound of a Cracked Kettle" is 
used by Laennec, because there is a resemblance 



42 THE CRACKED-KETTLE SOUND. 

to the sound produced by striking a cracked 
kettle. It was formerly considered as a pathog- 
nomonic sign of caverns; but it is not so. It 
is but seldom heard over caverns, because in 
such a case the conditions necessary to its pro- 
duction are usually wanting. This arises from 
the fact that by the force of the percussion 
the thoracic wall is pressed a little inward, and 
the space of the cavern made smaller. The 
sudden passage of the air out of the cavern 
into the much narrower bronchus produces this 
sound. For the production of this sound, it is 
also necessary that the thoracic wall be thin and 
yielding, the cavern tolerably large and situated 
superficially and in free communication with the 
bronchus. Of course these conditions are ful- 
filled in the case of the smallest caverns. When 
the percussion is feeble and the ear is held at 
some distance from the thorax, a feeble clanging 
sound can easily be heard, which becomes more 
perceptible if the patient open the mouth. 

The cracked-kettle sound appears occasionally 
in the case of superficially situated caverns ; in 
pneumonia in the region of the tympanitic sound; 
in pleuritic exudation in the region of the large 
bronchi; even in simple bronchitis and in com- 
pletely healthy persons, particularly with chil- 
dren. According to Traube, it is produced by the 
passing of the air out of a larger space through 
a narrow opening. In children the air-containing 



THE CRACKED-KETTLE SOUND. 43 

space is represented by the whole lung, and the 
narrow opening by the glottis. The clanging 
sound is heard most frequently under the clavi- 
cle, and with it usually a dull, high sound. If 
the latter appears with it, it is safe to decide that 
there are caverns. A strong, short percussion 
stroke is best adapted to bring out the clanging 
sound. A quite similar sound arises, besides, 
from the unskillful placing of the pleximeter 
when a little air remains under it, 

Wintrich introduces still another modification 
of the cracked-kettle sound (bruit de pot fele), 
which may be heard by striking on the thorax of 
any individual when singing, speaking, or crying. 
His explanation is this : that the regular vibra- 
tions of the vocal chords in speaking, singing, 
and crying, which by the pressure of the com- 
pressed air become disturbed and irregular, do 
not, properly speaking, give a tone, but a sort 
of clinking noise. In the same way he explains 
the ringing sound, like that of coin, entirely simi- 
lar to that of the above-named clinking sound, 
which may make its appearance in hollow cavi- 
ties, and which yields a metallic sound whether 
the cavities be caverns or the lower part of the 
trachea. The latter produces the metallic sound 
under the same conditions as the tympanitic. 
(Williams's Tracheal Sound.) Thus both sounds 
are a modified metallic ring, resembling that of 
the clinking sound, but of momentary duration. 



44 THE RELATIONS OF PERCUSSION 

The hydatid trill, which Piorry laid down as 
characteristic of the sac of the Echinococcus, is 
probably a feeling of fluctuation produced during 
percussion. It can be perceived in the same 
manner when one shakes such a sac back and 
forth in the hand. 



The Relations of Percussion to the Normal Thorax. 

In the infra-clavicular region, between the 
clavicle and the third rib, the percussion sound 
is loud and deep ; it is louder here than any- 
where else on the thorax. This is chiefly to be 
explained by the greater thinness of the thoracic 
wall; for this reason it also appears less loud 
when there is good development of the pectoralis 
major in the outer parts of this region. In the 
fossa supra-clavicularis the sound is likewise loud, 
and, indeed, somewhat louder than in the outer 
part of the infra-clavicular region ; in respect to 
depth, it is not quite so deep as in the latter 
case. But, if the sound in the fossa supra-clavic- 
ularis seems dull in comparison with that in the 
infra-clavicular region, the former must be con- 
sidered in an abnormal state. In this region it 
is necessary to place the pleximeter close to the 
clavicle, over the outer edge of the sterno-cleido- 



TO THE NORMAL THORAX. 45 

mastoideus, otherwise the sound becomes accom- 
panied by a weak tympanitic sound. 

Near the sternum the clavicular region gives 
a less loud and deep sound than the infra-clavicu- 
lar region ; on the acromial half of the clavicle 
the sound is duller than on the sternal portion. 
For percussion in this region, it is especially 
necessary, as almost everywhere else, to compare 
corresponding points; that the shoulders stand 
upon the same level, and that the hammer be 
made to strike the pleximeter in the same direc- 
tion on both sides. 

These three regions always deserve special 
attention, because tuberculosis generally begins 
on the apices and upper parts of the lungs, and 
there first becomes of diagnostic significance, 
often, indeed, at a time when Therapeutics can 
still effect much. 

The mammillary region, extending from the 
infra-clavicular region to the fourth rib, inclu- 
sive, gives a deep, non-tympanitic sound, some- 
what less loud than beneath the clavicle. The 
small degree of dullness in sound may be ac- 
counted for by the stronger development of the 
lower part of the pectoralis major, and by the 
skin being somewhat thickened by adipose struc- 
ture, — the female breast not being at all consid- 
ered. Under the fourth rib the sound becomes 
still a little less loud and high, and, from the 
sixth rib downward, intensely dull. The bound- 

5 



46 THE RELATIONS OF PERCUSSION 

ary between the lesser and greater dullness marks 
the margin of the lung. At the left the per- 
ceptible dullness of sound commences at the 
third rib, and proceeds thence downward, attain- 
ing its greatest breadth in the fifth intercostal 
space (cardiac dullness). The dullness is great- 
est near the sternum. In deep inspiration and 
in emphysema this dullness becomes less, and 
in emphysema may wholly disappear. 

Under the sixth left rib the sound, a little 
dulled by the left lobe of the liver, is high and 
clearly tympanitic. The tympanitic sound is 
derived from the air-containing stomach, which 
influences the sound. This space of tympanitic 
timbre, the only one in the whole thorax, is 
called the crescent-shaped region. It has nor- 
mally a breadth of three inches ; by contraction 
of the left lung it becomes greater, by hepatiza- 
tion and pleuritic exudation less. Exudation not 
merely presses the diaphragm downward, but it 
also presses the stomach downward and to the 
right. Then the tympanitic timbre disappears, 
and the zone shows a strong degree of dullness. 
The beginning of absorption is first indicated by 
'increase in the breadth of this space. 

The sternal region can be divided into four 
different sections : the sound of the manubrium 
is loud and deep, but less loud than on the ster- 
nal part of the infra-clavicular region. No lung- 
substance lies under the manubrium, but only 



TO THE NORMAL THORAX. 47 

the anterior edges of the lungs reach clown- 
ward along its lateral margins until they almost 
touch each other on a level with the second 
costal cartilage. On account of the nearness of 
the edges of the lungs, the sound of the manu- 
brium is not wholly dull. 

On the upper part of the body of the sternum 
the sound is more or less loud than on the man- 
ubrium, because the anterior edges of the lungs 
on a level with the second rib, the boundary be- 
tween the manubrium and corpus sterni, almost 
touch each other. Cardiac dullness begins at 
the third rib. On the xiphoid process, under 
which the left lobe of the liver lies, the sound 
shows a great degree of dullness ; the stomach 
occasionally imparts to it a tympanitic tone. 

The marginal regions of the sternum impart 
a loud and deep sound as far as the fourth rib ; 
between the fourth and eighth ribs it is higher 
and a little less loud. In the right marginal re- 
gion the dullness of sound produced by the liver 
begins at the seventh or eighth rib. On the left, 
under the seventh rib, a slightly tympanitic 
sound occurs, which at the ninth rib is rendered 
dull by the spleen. Between the sixth and sev- 
enth ribs, on the left, lies the lower margin of 
the lung ; it is, therefore, to be inferred that with 
this margin the high tympanitic sound ceases. 

The percussion sound is in general much 
duller on the back than on the front of the body, 



48 THE RELATIONS OF PERCUSSION, ETC. 

on account of thick muscular layer. It indicates 
the greatest degree of dullness over the shoulder- 
blades, and next in the supra-spinous regions, 
where it is also higher.- These regions have the 
same importance as the clavicular region in diag- 
nosis of tubercular disease. Especially must at- 
tention be paid to the shoulders being held on a 
level, and to the percussion of exactly corre- 
sponding points : for near the acromion the dull- 
ness is much more perceptible than near the 
spinous processes. The inter-scapulary region 
gives a less dull sound than the scapulary region ; 
the greatest degree of dullness is indicated on 
the vertebral column. The sound of the percus- 
sion is louder and deeper in the infra-scapulary 
region than anywhere else on the back, but not 
so loud and deep as on the front of the body. 
Towards the lower edges of the lungs, near the 
eleventh rib, the percussion sound is accompanied 
by a slight tympanitic sound, produced by the 
air-containing organs in the abdomen. In what 
manner the mobility of the edges of the lungs 
can be investigated by the sound of percussion 
in inspiration and expiration, has been already 
mentioned. 



PECTORAL FREMITUS. 49 

Pectoral Fremitus. 

By the term pectoral fremitus we are to under- 
stand certain sensible vibrations of the thorax, 
which are transmitted by the voice to the thoracic 
walls. There are also other loud sounds on the. 
thorax which may be felt, viz., rattling, wheezing, 
and frictional; but they do not belong under this 
head. 

The fremitus is best tested by the points of the 
fingers. By using the whole hand one often 
touches points possessing different degrees of 
vibratory power. 

The pectoral fremitus is much stronger in a 
deep than in a high voice, and in a whistling 
voice we can scarcely perceive it. The farther 
from the glottis palpation on the thorax be 
made, the weaker the fremitus appears, as may 
easily be conceived. But normally it is nowhere 
wanting except in weak or high voices, particu- 
larly those of women and children ; it may fail 
on the lower or even on the upper part of the left 
portion of the breast. In old people the fremitus 
is usually stronger, according to Scoda for this 
reason, that the bronchial cartilages increase in 
thickness and hardness with age. On the right 
side the fremitus is absolutely stronger than on 
the left. On the right side its weakening has 
much more significance than on the left. This 
difference is perhaps to be explained in this way : 

5* 



50 PECTORAL FREMITUS. 

that the right bronchus is wider and shorter, and 
passes off at a shorter angle, than the left one. 
The fremitus is very weak on the shoulder-blades, 
especially on the spine of the scapula, and also 
on the manubrium of the sternum, under which 
no lung-structure lies. Over the spleen, liver, 
and heart the fremitus is wholly wanting. When 
the patient is lying down, the fremitus is strong- 
est; it usually changes with the position, and 
therefore he should always be examined in the 
same condition. It becomes weakened through 
everything which interferes with the transmission 
of the vibrations through the vocal chords. 

(1) By the thickness of the thoracic wall ; on 
this account it is weak on the shoulder-blades 
and on the female mammary glands. (Edema, 
abscesses, extravasation beneath the skin of the 
thorax, also weaken the fremitus. 

(2) By obstruction of the bronchi by matter, 
blood, or mucus. 

(3) By pneumothorax. 

(4) By large tumors, abscesses, and gangrenous 
destruction of the lungs, if these affect a large 
part of the lungs. 

(5) By pleuritic exudation. Here, as in pneumo- 
thorax, it may increase above fluids or gases, 
where the tympanitic sound appears, but cor- 
responding to the site of the fluids it is much 
weakened. The pectoral fremitus is of great 
importance in the diagnosis of limited pleuritic 



PECTORAL FREMITUS. 51 

exudation, which is sometimes difficult to dis- 
tinguish from pneumonia and induration of the 
connective tissue. When the fremitus is dimin- 
ished or obliterated over the point of dullness, 
it is conclusive proof of pleuritic exudation ; if 
it manifests itself normally or augmented, it is 
proof of thickening of the lung-tissue by hepa- 
tization or induration of the connective tissue. 
In pleuritic exudation upon the right side it may, 
however, occur that, after absorption has com- 
menced, the fremitus on the upper part of the 
region of dullness equals that upon the left side. 
The fremitus becomes stronger : 

(1) When the parenchyma and walls of the 
bronchi are thickened either from hepatization, 
tubercular deposit, chronic induration, or from 
compression resulting from chronic collections 
of gas or fluid in the pleural cavity. 

(2) Caverns strengthen the fremitus in the same 
way when their walls are thickened. But they 
must be situated tolerably near the periphery, 
contain air, and either communicate freely with 
the air in the trachea, or be cut off from the 
same by a moderate stratum of lung-structure. 

In regard to the rhonchi which may be felt, 
as rattling, whistling, wheezing, and rubbing, it 
may be added, further, that these sounds arise 
from the vibration of viscid portions of mucus, not 
always existing in the place where the sound is 
to be heard or felt. It is often so strong as to 



52 PECTORAL FREMITUS. 

transmit itself from the larynx over the whole 
thorax. A strong fit of coughing, which re- 
moves the mucus from the larynx, annuls the 
fremitus in it as well as in the thorax. A widely 
extended fremitus by no means proves a diffuse 
collection of mucus. 

The pleuritic frictional sound is also often per- 
ceptible to feeling. It occurs when false mem- 
branes on the costal and pulmonary pleura glide 
over each other in breathing. 

The gurgling in the abdomen is produced in 
the intestines by bubbles of air passing through 
fluids. It is mostly perceptible to touch, as in 
ileo-typhus in the ileo-caecal region. 



AUSCULTATION. 



(53) 



AUSOULTATIOK 



Auscultation is practiced on the respiratory 
and circulatory organs, either immediately, by 
laying the ear on the spot, or mediately, by 
means of the stethoscope, and thus listening to 
the tones or rhonchi arising on the spot. 

The stethoscope is indispensable for the ex- 
amination of circumscribed points, particularly 
in auscultation of the heart. 



CHAPTER I. 

AUSCULTATION OF THE RESPIRATORY ORGANS. 

The sounds perceived over these organs are 
divided into respiratory sounds, produced by the 
passage of the air along the walls of the respira- 
tory organs, and rattling sounds, or rhonchi, 
which are produced by the meeting of air and 
water in the air-passages. 

(55) 



56 RESPIRATORY MURMURS. 

A. Respiratory Murmurs. 

(a) The vesicular or whispering labial respira- 
tory murmur, according to Scoda, may be imi- 
tated by the mouth, if, during a somewhat strong 
respiration, the lips pass by degrees from the 
position they assume in giving the sound of the 
letter V to that necessary to produce the sound of 
F. It appears in inspiration as well as in expira- 
tion ; but in the latter in a normal state the respir- 
atory murmur may not be positively perceptible. 

It is usually said that the vesicular murmur 
arises from the friction of the air on the walls 
of the pulmonary vesicles, whence it derives its 
name. But no one has yet been able to prove 
this opinion correct, and with equal uncertainty 
can any other statement of its origin be made. 
This murmur assumes various shades : a mild, 
vesicular murmur when it begins with the sound 
of V; sharp, when it begins with that of F; 
deep, when sounded through the letter ; and 
high, when through the letter A. 

The vesicular respiratory murmur with the A 
tone is heard most frequently in old people, and 
somewhat resembles the bronchial breathing. It 
cannot be imitated with the mouth. Further, 
the vesicular respiratory murmur is loud or weak, 
distinct or indistinct. The two varieties are not 
identical ; a sound may be loud, but, according 
to its character, it may be non-vesicular, and yet 



RESPIRATORY MURMURS. 57 

undefined. The abnormally loud vesicular mur- 
mur was named by Laennec" puerile breathing," 
because in children under normal conditions a 
much louder respiratory murmur is heard ; it is 
heard in grown persons when one healthy lung 
performs the functions of the other, on account 
of the respiratory action of the latter being im- 
peded, as in pneumonia, pleuritis, and contrac- 
tion of the lung. On the diseased side a very 
weak vesicular murmur is heard. It is heard 
abnormally loud on the upper anterior part, 
where the collection of secretion renders the 
passage of air through the bronchi of the lower 
part impossible, as in chronic bronchial catarrh 
in opposition to chronic tuberculosis, in which 
case anteriorly and above only a weak vesicular 
murmur is heard. It also appears weakened in 
miliary tuberculosis, when the morbid centers 
are very numerous. 

The vesicular respiratory murmur also becomes 
weakened by inspiration which is both long and 
deep ; and further, in all cases where the alveoli 
offer less resistance to the entering air, as in re- 
laxation of the lung-structure and in emphysema. 
Finally, a diminution or disappearance of the 
vesicular murmur is always found when the 
bronchi or alveoli can receive little or no air. 
This takes place when they are obstructed or com- 
pressed by pleuritic exudation, w^hen the air pass- 
ing into the larynx, trachea, or a large bronchus 

6 



58 AUSCULTATION OF RESPIRATORY ORGANS. 

meets with some hinderance, and when, in conse- 
quence of costal injury or of severe pain, the re- 
spiratory action of a part of the thorax is injured. 
Where there is a considerable narrowing: of the 
upper air-passages, by false membranes, by cica- 
tricial contraction, or by pressure from tumors or 
from foreign bodies on the thus narrowed place, 
a loud, whizzing sound can be heard, which may 
even extend far and wide over the thorax. 

The vesicular murmur becomes rough when 
the mucous membrane of the bronchi and alveoli 
is swollen and causes too great friction, as in 
bronchial catarrh. 

The longer or shorter duration of the vesicular 
murmur depends upon the duration of expiration 
and inspiration. Lastly, this sound may be heard 
in combination with other sounds, — viz., rattling, 
whistling, wheezing, — and even with bronchial 
breathing. When the ear is held at some dis- 
tance, the bronchial breathing is transmitted to 
the point of vesicular murmur and is perceived 
at the same time with it. 

In regard to diagnosis, we cannot with certainty 
conclude that where the vesicular murmur is 
heard, the lungs throughout are in a normal 
state. After death, miliary tubercles or small 
tubercular infiltrations are often found, although 
the perfect vesicular murmur had been heard. 

It may also be wanting anteriorly or posteriorly 
in the upper parts of the lungs, sometimes in per- 



RESPIRATORY MURMURS. 59 

fectly healthy persons, particularly in slow and 
feeble inspiration. The murmur is then uncle- 
fined. We cannot with certainty conclude upon 
pathological change in the parenchyma of the 
lungs from the absence of the vesicular murmur 
in the above-named localities. But the conclu- 
sion is safe, that where the vesicular murmur is 
heard, there is healthy parenchyma. 

(b) The Bronchial or Loud Respiratory Murmur. 
— This can be imitated by placing the tongue in 
such a position during inspiration and expiration 
as would be necessary to produce the sound of 
K in the throat. The consonant with which 
this sound corresponds may also be an H. Ac- 
cordingly, the bronchial respiratory murmur may 
be sharp or soft. The vowels o, u, a, e, or i may 
also sound in it, and in accordance therewith we 
distinguish a deep and a high sound. Lastly, the 
sound appears loud or weak, distinct or indis- 
tinct. This respiratory murmur has the name 
." bronchial breathing," because formerly it was 
thought to originate in the bronchi only. But 
it has since been proved that its origin is in the 
larynx and trachea. In a normal state the bron- 
chial breathing is only heard in the throat; often, 
particularly in thin persons, in deep and quick 
respiration it extends along the vertebral column 
to the point where the trachea divides, thence on 
to the fourth thoracic vertebra, coinciding with 
which it is sometimes heard anteriorly on the 



60 AUSCULTATION OF RESPIRATORY ORGANS. 

manubrium of the sternum. Sometimes also the 
inner part of the supra-spinous region, the whole 
inter-scapulary region, the supra-clavicular re- 
gion, the inner part of the clavicular and infra- 
clavicular region, give the sound of the bronchial 
respiratory murmur ; but it is very seldom given 
by the outer part of the supra-spinous region, the 
region around the nipple and beneath the spine 
of the scapula. By means of certain positions of 
the mouth and a croupal breathing, perfectly 
healthy persons can produce a bronchial respira- 
tory murmur, so loud that it can be heard over 
the whole thorax. 

It is very important, and often very difficult, to 
distinguish the transmitted bronchial breath from 
that which results from change in the structure of 
the thorax. The transmitted sounds can be re- 
cognized thus : they vary in height and depth 
according to the voluntary elevation and deepen- 
ing of the sounds produced in the mouth, viz., 
the opening and closing of the mouth. This cir- 
cumstance proves conclusively that they can be 
transmitted, but it does not refute their patho- 
logical origin, since abnormal bronchial breath- 
ing is also susceptible of transmission. Further, 
the transmitted sounds are, as a rule, heard on 
both sides, in which they sound high or low as if 
coming from a distance. They often have a pe- 
culiar sound similar to the metallic ring. Still, 
these circumstances do not surely indicate the 



TEE BRONCHIAL MURMUR. 61 

transmitted nature of the bronchial breathing. 
But in certain regions the intensity of the sound 
indicates its pathological origin or otherwise. 

In a normal state, in the supra-spinous and infra- 
clavicular regions bronchial breathing may now 
and then be perceived, but only in a slight degree. 
Loud bronchial breathing in these regions al- 
ways authorizes us to accept pathological causes 
for it, such as degeneration of the lung-struc- 
ture. The pathological origin of the bronchial 
breathing is further confirmed by the fact that 
toward the throat it diminishes in intensity; but 
if the condition be reversed, and there be a 
gradual strengthening of the bronchial breathing 
toward the throat, still we can by no means de- 
cide upon the integrity of the lungs. In many 
cases we must resort to other symptoms in order 
to decide conclusively upon the nature of the 
bronchial breathing ; especially must we resort 
to percussion. If bronchial respiration be heard 
on one or both sides of the lower and posterior 
parts of the thorax, and the same be deep and 
sharp, it may be taken for granted that it is pro- 
duced by change in the structure of the lungs, 
and a dullness of the percussion-sound banishes 
all doubt. But if bronchial breathing upon both 
sides arises on the upper parts of the back, still 
one side may be completely healthy, since the 
sounds may be transmitted from one side to the 
other. Percussion then decides the question. 

6* 



62 AUSCULTATION OF RESPIRATORY ORGANS. 

The determination of this question is very im- 
portant. Pneumonia upon one side may admit 
of a favorable prognosis, but not so a pneumonia 
duplex, since a double pleurisy is usually associ- 
ated with the latter. 

The bronchial breathing is heard in inspiration 
as well as in expiration, but generally more dis- 
tinctly in the latter, although from the greater en- 
ergy of inspiration one would judge the contrary. 
The following conditions are necessary to the 
production of the bronchial respiratory mur- 
mur: (1) Condensation of the parenchyma; 

(2) the part of the parenchyma containing 
little or no air must lie near the thoracic wall ; 

(3) it must be sufficiently extensive to take in 
several large bronchi ; (4) it must have free. com- 
munication with the trachea. The bronchial 
respiratory murmur is heard in the following 
diseases : 

(1) In pneumonia. Here the tissue is solidified 
by fibrinous exudation which fills the alveoli. 

(2) In pleuritic exudation, when through long- 
existing compression the tissue of the lungs has 
become emptied of air, while the bronchi remain 
open. At first, in pleuritic exudation, the vesicu- 
lar respiratory murmur is more or less loud, since 
the exudation is, as yet, inconsiderable. To- 
ward the end, when the exudation has become 
partly absorbed and the lungs can again expand, 
at first an undecided, afterward a decided vesic- 



THE BRONCHIAL MURMUR. 63 

ular murmur is heard, the intensity of which 
continually increases as the exudation disap- 
pears. 

(3) The bronchial respiratory murmur appears 
in solidification of the lung-structure in case of 
tuberculosis and hepatization. Here it is devel- 
oped from the larynx and trachea. It can be 
recognized by this, that toward the throat it in- 
creases in intensity and changes its height and 
depth with the opening and closing of the mouth. 
In solidification of the parenchyma, the walls of 
the bronchi become more rigid and have greater 
power of reflecting sound, more nearly resem- 
bling that of the trachea and larynx. Thereby 
the sounds arising in the latter can be trans- 
mitted into the smallest bronchi without losing 
much in intensity. For the same reason the 
bronchial respiratory murmur is also heard. 

(4) In case of caverns and bronchial dilatation. 
These represent, so to speak, a primitive bron- 
chus, which is in free communication with the 
trachea. The more superficially, the nearer the 
thoracic wall these lie, the louder is the bron- 
chial murmur. The last condition causes the 
loudest respiratory murmur to be heard in case 
of caverns and bronchophony. But the bron- 
chial murmur can also arise in bronchial dilata- 
tion and caverns. When the respired air passes 

• over the mouth of a closed primitive bronchus 
inclosed in condensed lung-structure, it sets the 



64 AUSCULTATION OF RESPIRATORY ORGANS. 

column of air within the same into vibratory 
motion, as in blowing over a hollow key, and 
thus the bronchial breathing is produced. In the 
same way the bronchial breathing occurs in dila- 
tation of the bronchial tubes and caverns. Also 
sounds which arise from slightly contracted con- 
tiguous bronchial tubes, which are still permea- 
ble to air, even the bronchial breathing itself, 
which originates in the larynx, may have the 
effect of creating a sound in the confined columns 
of air in closed bronchi, bronchial dilatation and 
caverns. In diagnosis it must be borne in mind 
that only where there is a combination of several 
diseases can any decisive opinion be formed from 
the bronchial breathing; not where there is one 
special disease: in order to decide the question 
of any special disease, other symptoms must be 
brought to our aid. 

(c) The Indefinite Respiratory Murmur. — Ac- 
cording to Scoda, this is that respiratory sound 
which has the character neither of pure vesicular 
nor of bronchial respiration, and is, besides, un- 
accompanied by the amphoric or metallic sound. 
This may be either loud or weak, distinct or in- 
distinct, but must always be distinguished from 
vesicular and bronchial respiration. Normally it 
may now and then be heard in the supra-spinous 
regions, even in rapid respiration. In children 
it often has a bronchial intonation. In quiet 
respiration it may be heard over the whole tho- 



THE EXPIRATORY MURMUR. 65 

rax even in the strongest persons. This indefi- 
nite respiratory murmur, appearing under normal 
conditions, may always be heard correspondingly 
on both sides : if heard on only one side, there 
always exists an abnormal condition of the lungs, 
the nature of which can be decided upon only by 
a grouping together of other symptoms. 

(d) Expiratory Murmurs. — Vierordt and Lud- 
wig have found that the length of inspiration 
compared to that of expiration is as 10 to 14 ; 
the second number may vary, however, between 
14 and 24. In auscultation the duration is in an 
inverse ratio. The expiratory murmur is never 
so long and strong as the inspiratory; it may 
even be indeterminate, while the inspiratory 
murmur distinctly manifests a vesicular charac- 
ter. The explanation of this is, that in inspira- 
tion, which is an almost totally passive act, the 
air passes out of the lungs much more slowly 
than it passes into the lungs in inspiration, which 
latter is effected by strong muscular power. The 
sound of expiration is longest and strongest on 
the upper part of the breast; as we trace it 
downward it disappears by degrees, until finally 
it is no longer heard. Moreover, in the region 
of the apices of the lungs, the sound of expira- 
tion is often stronger on the right than on the 
left, and in the right supra- and infra-clavicular 
regions it is now and then lengthened and 
slightly bronchial. Pathological change in the 



66 AUSCULTATION OF RESPIRATORY ORGANS. 

lungs may also be decided upon from distinct ex- 
piratory murmur below, as well as from loud and 
long expiratory murmur, particularly when the 
inspiration is at the same time shortened and 
weakened. But from this condition of the sound 
of expiration we can only draw the general con- 
clusion that an obstruction exists in the bronchi 
which opposes the outward passage of the air. 
Bronchial catarrh and tuberculosis are the dis- 
eases which usually lengthen and strengthen the 
respiratory murmur. But from an inequality 
on one side or a strengthening of the expiratory 
murmur on both sides we can by no means decide 
upon any disease of the lungs, particularly upon 
tuberculosis, without the addition of still other 
symptoms. If, however, on one side, together 
with a strengthened and lengthened expiration 
there exist at the same time a shortened and 
weakened inspiration, we can with much proba- 
bility infer the existence of tuberculosis. In 
bronchial catarrh the rattling sound (rhonchus) is 
always heard. 

(e) The Interrupted Respiratory Murmur^ Laen- 
nec's Respiration saccadic — The inspiratory mur- 
mur, and less frequently the expiratory murmur, 
are sometimes marked by two or three interrup- 
tions. The individual portions of the sound so 
interrupted also change not unfrequently in char- 
acter and strength : to wit, the first may be loud 
and distinctly vesicular, the second weak and 



RHONCHI. 67 

undefined, and the third again loud and distinctly 
vesicular. The vesicular as well as the unde- 
fined murmur may be of an interrupted nature 
(saccadirt). It was formerly considered a pathog- 
nomonic symptom of tuberculosis. But it proves 
nothing beyond the existence of abnormal causes 
of resistance, which present a continued and 
uniform expansion of the lungs. The inter- 
rupted respiration (saccadee) also appears in 
anxious breathing, in spasmodic conditions and 
pain in the walls of the thorax, as well as in the 
cold stage of different acute diseases. But if 
this is heard for a length of time beneath the 
clavicula, we may suspect tuberculosis, and at 
any rate it indicates chronic disease at the apex 
of the lungs. Pleuritic frictional sounds may 
also appear interrupted in like manner. 

B. JRhonchi. 

If the bronchi are here and there contracted, 
or if viscid mucus anywhere in the larynx, tra- 
chea, or bronchi is set in vibration by the air, 
then noises of a whistling or rattling nature 
arise, which we usually call dry rhonchi, or dry 
rattling sounds. The name is not well adapted, 
since for their existence humidity, viz., viscid 
mucus, is necessary. Therefore the definition of 
rhonchus siccus, dry rhonchus, is very indefinite, 
since under this head can be and have been in- 



68 AUSCULTATION OF RESPIRATORY ORGANS. 

eluded all sounds which are neither respiratory 
murmurs nor so-called moist rhonchi. The latter 
arise when the air passes into the bronchi through 
a more or less copious thin secretion. It is more 
appropriate, instead of using the term dry rhon- 
chi, to separate the two well-characterized sounds, 
viz., the whistling, or rhonchus sibilans, and the 
rattling, or rhonchus sonorus. (a) The whis- 
tling sound resembles the whistling of the wind 
passing through narrow openings; the rattling 
sound resembles the tone of a slack bass string. 
If the vibrating column of air is long and the 
tube large, or if the tone-producing vibration is 
slow, then a deep sound arises, namely, the 
rattling sound; in the opposite cases, the whis- 
tling or sibilant sound. The latter appears espe- 
cially in the glottis and in the small bronchi, — 
that is, where the caliber is narrow; the rattling 
appears oftener in the larynx, trachea, or larger 
bronchi. Not unfrequently these sounds change 
their place, or are only to be heard from time to 
time : for example, they often disappear after a 
paroxysm of coughing. Consequently, they have 
no particular diagnostic importance. If they are 
constantly heard in the same place, even after 
temporary disappearance, and are to be perceived 
with slight intermissions for weeks or months, 
and, further,- if they always preserve the same 
character, then they indicate structural change in 
the Hmgs. A general whistling sound, continuing 



RHONCHI. 69 

for a long time, is always a proof of dry catarrh. 
In nervous asthma (acute dry catarrh), whenever 
the catarrh manifests itself, a whistliug sound is 
constantly heard. The intervals between its re- 
peated manifestations become shorter and shorter, 
and finally acute dry catarrh becomes chronic. 
In chronic bronchial catarrh more or less abun- 
daut and large vesicular rhonchi appear on the 
posterior lower parts of the thorax; on the an- 
terior upper parts sharpened vesicular breathing 
is heard. The whistling sound is likewise to be 
heard in tuberculosis, and usually on the apices 
of the lungs, (b) The rattling sound also appears 
in catarrh when the secretion is viscid. In re- 
gard to intensity, these sounds differ very much. 
Now and then they are very weak; but they 
usually sound louder than the respirator mur- 
murs, and are often heard even at a little distance. 
They then arise either in the wide parts of the air- 
passages, especially in the larynx and trachea, or 
they have their origin not far from the thoracic 
wall. A loud whistling sound is not perceived 
by means of palpation, but a loud rattling sound 
may possibly be. From a rhonchus heard over 
a large space an extended change cannot be in- 
ferred, as before mentioned. There is a rhon- 
chus called the consonant or according murmur. 
It is best indicated in this way, that it seems to 
arise directly beneath the ear. Where it is heard, 
changes must have occurred which" permit a 

1 



70 AUSCULTATION OF RESPIRATORY ORGANS. 

ready transmission of sound. In this case we 
infer secretion from the larger bronchi and thick- 
ening of the surrounding parenchyma. 



Crepitant Rhonchus, or the so-called Humid Crepi- 
tant Rhonchus. 

In these we hear the same sounds divided into 
parts, which are distinctly separated from each 
other by pauses. These fractional sounds arise 
from the bursting of air-containing bubbles of 
fluid. The fluid present must also be suffi- 
ciently viscid to form bubbles. The name of 
the crepitant rhonchus has undergone many 
changes. 

Laennec's terminology was characterized by a 
great number of names, which for the most part 
sprang from false views, and showed a tendency 
to infer a definite disease from one symptom 
alone. Thus, he named the loud, medium, crepi- 
tant, ringing rhonchus, cavernous rhonchus; but 
from it one can by no means conclude with cer- 
tainty that cavities exist. His mucous rattling, 
rhonchus mucosus, may arise either from a collec- 
tion of pus or of blood in the bronchi. Scoda 
pruned his terms carefully; but he, with his ac- 
cording or consonant sound, has also introduced 
a badly-adapted terminology. He understands 



RHONCHI. 71 

thereby the ringing crepitant sound, and has con- 
ceived it to be an instance of resonance. But 
the ringing nature of this sound depends upon 
the same causes as the bronchial breathing, 
which, as before mentioned, is not the result of 
resonance. Traube names the crepitant rhonchi 
according to their properties: (1) they are either 
scanty or abundant. Abundant, when they con- 
sist of several fractional parts of sound, which 
occupy the entire period of inspiration or of ex- 
piration. In case of abundant crepitation there 
need not be much fluidity in the bronchi, nor 
in scanty crepitation need there be but little. 
In the large bronchi, even with a small degree 
of fluidity, the current of air can produce an 
abundant crepitation. 

A second property is to be deduced from the 
size of the vesicles. According thereto, we 
may distinguish — (a) the large vesicular crepita- 
tion. This can only arise in abnormally large 
cavities within the lungs, which cavities are 
larger than the largest bronchi, for in narrow 
spaces the formation of large bubbles of fluid is 
impossible, (b) The medium vesicular rhonchus. 
This can only arise in the medium-sized bron- 
chial tubes when there is fluidity therein, (c) The 
small vesicular crepitation. This can be formed 
only in the small bronchial ramifications, (d) The 
minute vesicular crepitation or vesicular murmur 
(Laennec's rhonchus crepitans). Laennec com- 



72 AUSCULTATION OF RESPIRATORY ORGANS. 

pares this to the crepitation or crackling of salt 
in a heated vessel, or to the noise which arises 
when an air-containing lung is pressed together 
with the fingers, or when a stethoscope is lightly 
pressed upon it. According to Williams, it is 
exactly similar to the sound produced by rubbing 
a lock of hair with the fingers close to the ear. 
This has usually been explained thus: that the 
air passes through fluid into the smallest bron- 
chial ramifications and alveoli, and creates bub- 
bles which forthwith burst. Wintrich opposes 
this view, and shows, in a convincing manner, 
that this rhonchus arises if the walls of the small- 
est tubes and alveoli, which have become slightly 
adherent by mucus, are suddenly torn asunder by 
the in-rushing current of air. In this separation 
the number of rhonchi corresponds to the num- 
ber of vesicles and small bronchial ramifications 
which were filled up ; the aggregate of these 
sounds gives the crepitation. If air be blown 
into an eviscerated lung, the crepitation is always 
heard, because it has contracted so much that the 
walls of the alveoli and of the smallest tubes are 
in contact. If the air be allowed to escape again, 
then no crepitation is heard. Within the closed 
thorax the lungs can never contract so much 
that the walls of the alveoli and smallest tubes 
can become adherent; thus, in a healthy con- 
dition of the lungs a proper crepitation can 
never arise. But if the mucous membranes of 



RTIONCIII. 73 

the vesicles and finer bronchial tubes swell and 
become covered with mucous or viscid pneu- 
monic exudation, then it is easy to conceive that 
during expiration the walls may so approach 
each other that a degree of adhesion may take 
place. If now a strong respiratory current be 
forced into the lungs during the dilatation of 
the vesicles, the adherent walls are separated 
from each other, and thereby arises the crepitant 
rhonchus. During expiration the walls approach 
each other again until they become adherent, 
but their approach to each other can be accom- 
panied by no rhonchus. Even the strongest ex- 
piration and the hardest coughing produce no 
crepitant rhonchus, nor do they remove it. It is 
only heard during inspiration. 

The fine vesicular rhonchus is perceived : 

(1) In the first stage of pneumonia, where the 
mucous membrane is swollen and the exudation 
is viscid. 

(2) In that stage of ordinary pneumonia in 
which the exudation becomes soluble. 

(3) In acute and chronic tubercular pneu- 
monia. 

(4) In oedema of the lungs; but here only sel- 
dom. The serous exudation may, by its albu- 
minous contents, be sufficiently viscid to bring 
the walls of the alveoli and bronchi to a state of 
adhesion. 

(5) In capillary bronchitis. 

f* 



74 AUSCULTATION OF RESPIRATORY ORGANS. 

(6) Not unfrequently a transitory, fine, vesicu- 
lar crepitation maybe heard in a limited number 
of unusually strong inspirations. This is wholly 
unimportant. The finest bronchial ramifications 
and alveoli are by turns brought into contact and 
become separated again, exactly as in eviscerated 
lungs. "When the patient makes a slow and 
superficial inspiration, then, in the cases named, 
the crepitant rhonchus is not heard; therefore it 
is necessary to cause the patient thus affected to 
inspire strongly and rapidly, although this gives 
him excessive pain. In obstruction of the lead- 
ing bronchi, or in obturation of the fine bronchi 
and alveoli, through coagulated exudation, also, 
there is, of course, no crepitation to be heard. 

Wintrich maintains that in pneumonia the 
crepitation may be loud and crackling, and 
thereby it is distinguished from oedema and 
capillary bronchitis. 

Laennec's subcrepitant rhonchus is a fine ve- 
sicular crepitation, that arises in the smallest 
bronchial tubes. It is usually heard during in- 
spiration and expiration ; only now and then in 
inspiration. Therefore it can with difficulty be 
distinguished from the crepitant rhonchus; it can 
neither be so loud nor so finely vesicular as the 
latter. 



RHONCHL 75 



Diagnostic Value of the Crepitant JRhonchus. 

Large vesicular crepitation proves the presence 
of fluid in abnormally large cavities, which are 
larger than the largest bronchi; consequently, 
in caverns and bronchial dilatation. 

Medium large vesicular crepitation indicates that 
fluid exists in the medium-sized bronchi. 

Small vesicular crepitation authorizes the con- 
clusion that there is fluid in the smaller bronchi. 

Fine and vesicular crepitation, when permanent, 
indicates that there is adhesive exudation in the 
bronchi and alveoli, and thickening of the mucous 
membrane. When a part of the lung has become 
solidified, the fine vesicular crepitation is an en- 
couraging sign. It proves that the alveoli have 
again become permeable to the air. The inten- 
sity of the crepitant rhonchi varies greatly. Sow 
and then they are so loud that they appear to 
arise close under the ear; sometimes, again, so 
dull that they are only to be perceived by very 
careful auscultation, and sound to the ear as if 
from a great distance. A loud crepitation proves 
that the parenchyma has become solidified, and 
the bronchial walls inelastic, or that the crepita- 
tion arises tolerably near the surface. "When 
neither condition is fulfilled, the patient may 
expectorate a great quantity of mucus without 
crepitation being heard. 



76 AUSCULTATION OF RESPIRATORY ORGANS. 

The dull crepitation offers no evidence in re- 
gard to the condition of the parenchyma. 

The crepitant, like the whistling and rattling 
rhonchi, are usually so intense and continuous 
that they completely mask inspiration or expira- 
tion, They are, in general, more frequent in in- 
spiration than in expiration, because the inspired 
current of air is by far the stronger. In regard 
to the place of its appearance, it may also be 
mentioned here that in the lower and posterior 
parts of the lungs the crepitant rhonchi appear 
oftener than elsewhere. This is simply the re- 
sult of the law of gravitation. In an upright at- 
titude, or in lying upon the back, the secretions 
gravitate backward and downward; hence, in 
diffuse chronic catarrh, in these parts the crepi- 
tation is most constantly and extensively heard, 
while in the upper parts, usually, sharpened, 
vesicular respiration, and in the middle portion a 
whistling and rattling or scanty crepitation, is 
heard. In diseases which confine the patient to 
the bed for a long time, the force of gravity in- 
duces catarrh in the inferior and posterior parts 
of the lungs, or, in already existing catarrh, 
causes a more copious secretion of mucus. The 
collection of the fluids is greater toward the lower 
posterior parts, consequently at the same time 
there gradually occurs hyperemia accompanied 
by increased secretion ; hence the frequent ca- 
tarrh of the regions named, — for example, in 
typhus. 



RHONCHI. 77 

But if we hear for a long time crepitant sounds 
in the upper parts of the lungs, it is a proof of 
deep-seated disease. A catarrh of these regions 
is either transient or it extends to other parts of 
the lungs. Therefore even a scanty crepitation, 
heard for a long time at the apex of the lungs, 
gives strong suspicion of pulmonary tuberculosis. 

According to the timbre, the crepitation is 
ringing or not ringing. The ringing crepitation 
is again divided into tympanitic-ringing and 
metallic-ringing crepitation. The tympanitic- 
ringing is most frequent; the metallic seldom 
occurs. The tympanitic-ringing crepitation indi- 
cates the same conditions as the bronchial respira- 
tion, namely, air- containing cavities which are 
surrounded by solidified pulmonary structure. 
From ringing crepitation we may with safety 
infer that there is solidification of tissue ; the 
bronchial respiration does not permit so decided 
an opinion, since there is often difficulty in sepa- 
rating a physiological bronchial respiration from 
a pathological one. Scoda, with his according or 
consonant crepitation, indicates the loud and ring- 
ing rhonchi, which two properties are usually 
combined. He thus invented one name for two 
properties. Such a nomenclature would lead to 
obscurity. His supposition that this crepitation 
arises from resonance, in which the air-cells and 
trachea bear to each other the relation of rever- 
berating walls, as already remarked, is erroneous. 



78 AUSCULTATION OF RESPIRATORY ORGANS. 

Here also the clicking sound is to be men- 
tioned ; it occurs most frequently at the apices 
of the lungs of tubercular persons, and on that 
account was named the tubercular clicking sound. 
It is a ringing-crepitant rhonchus, between the 
so-called dry and humid crepitant rhonchi. It 
arises in small spaces or bronchi, which are full 
of viscid secretion, when the surrounding paren- 
chyma and the walls of the bronchi are solidified 
by tubercular degeneration. 

The metallic-ringing crepitation arises from 
the same conditions as the metallic intonation of 
the voice and amphoric breathing ; the latter has 
a rather indistinct metallic sound. 

Almost all rhonchi, crepitation, wheezing, 
whistling, rattling, and bronchial respiration can 
assume the metallic timbre. The metallic ring 
can very well be imitated by blowing over the 
neck of an empty bottle that is not too large. 
The metallic timbre always authorizes the opin- 
ion that there are abnormally large air-contain- 
ing spaces in the lungs, which need not, however, 
communicate with the trachea, since the timbre 
can be heard not only in caverns, but also in 
pneumothorax. In the latter case the air-con- 
taining cavity is the space between the two 
laminae of the pleura. In this space no rhonchi 
arise, only in its vicinity sounds are produced 
and transmitted which receive here a metallic 
accompaniment, viz., bronchial respiration, bron- 



RHONCHI. 79 

chophony, and crepitation. If besides there is 
fluid in the pneumothoracic cavity, the metallic 
ring is also heard if the fluid be set in motion by 
the turning of the patient or by Hippocratic suc- 
cussion. If the patient is lying down, it very 
often occurs that the metallic sound is not at all 
heard, but as soon as he sits up it may be heard. 
In lying down, the level of the fluid rises, and is 
found more between those parts of the lung in 
which the rhonchus is produced and the thoracic 
wall. But the fluid is not in a condition to carry 
the sound-wave to the ear. The metallic timbre 
is of great diagnostic value, because it allows 
the concrete conclusion that there are caverns 
or pneumothorax. Independent of other signs, 
a partial pneumothorax may easily be distin- 
guished from caverns by means of percussion. 
In the first case the sound is loud, deep, and 
metallic ; in the latter it is higher and often ac- 
companied by the cracked-kettle sound (bruit de 
pot fele), and dull in the adjacent parts. 

Wintrich observed that in tubercular infiltra- 
tion of the lungs, reaching as far as the diaphragm, 
when the conducting conditions are good, the crep- 
itation, voice, etc. are transmitted through the 
diaphragm and walls of the stomach into the cavity 
of the stomach, and there produce ametallic sound. 



80 AUSCULTATION OF RESPIRATORY ORGANS. 



C. Auscultation of the Voice. 

In normal conditions, over the thorax of a per- 
son speaking, only a murmuring tone, without 
any articulation, is heard. The farther from the 
glottis auscultation is made, the weaker is the 
sound of the voice. The thickness of the thoracic 
wall is without particular essential influence. The 
thoracic voice can also be perceived on the lower 
parts of the lungs. It is stronger on the right 
side of the breast than on the left, as is the case 
with the fremitus pectoralis ; but this difference is 
much more marked in the latter instance. As 
already mentioned, the cause lies in the larger 
extent of the right bronchus. The modifications 
which the thoracic voice can undergo are : 

(1) Weakening, Suppression, and Strengthening. — 
It is weakened or suppressed when the con- 
ducting bronchus is made narrower or wholly 
obstructed by pressure or by accumulation of se- 
cretion. These obstructing bodies may also de- 
stroy the previous strongly intensified voice in 
the bronchi or hollow cavities; for example, an 
effusion of blood into a tubercular cavern. The 
thoracic voice also becomes weakened by all con- 
ditions which increase the distance between the 
bronchi and the thoracic wall, — by the presence 
of solid, fluid, or gaseous accumulations in the 



AUSCULTATION OF THE VOICE. 81 

pleural cavity. Under this head fall moderate 
pleuritic exudation and moderate pneumothorax, 
which may weaken the voice but cannot make it 
segophonic. The voice does not appear weakened 
in places where the lungs are made fast to the 
ribs by adhesions. (Edema, emphysema, or en- 
cysted tumors in the subcutaneous cellular tissue 
also produce a weakening of the voice ; adipose 
deposit has no influence. A moderate degree of 
emphysema of the lungs weakens the voice in the 
same way ; but if the walls of the bronchi are 
thickened and their caliber widened, then the 
voice appears even stronger. 

Very large hollow cavities also weaken the 
voice. According to Wintrich, the voice has to 
act simultaneously on too large a quantity of air, 
and is thus reflected inwardly and partially lost. 
Besides, the voice is usually conducted to such 
cavities through narrower and less numerous 
bronchial tubes than to medium-sized cavities. 

According to Wintrich, the strengthening of 
the thoracic voice never extends so far that it can 
be heard as strong on the thoracic wall as at its 
fountain-head, the glottis, — as is heard, for exam- 
ple, when the stethoscope is held on the mouth 
of a person speaking. It ordinarily holds a 
medium place between laryngophony and trache- 
ophony upon one side, and normal bronchophony 
as heard in the right half of the inter-scapulary 



82 AUSCULTATION OF RESPIRATORY ORGANS. 

region, coupled with deep voice and emaciated 
thorax. 

A strengthening of the thoracic voice takes 
place when the walls of the bronchi or abnormal 
hollow spaces have become thicker and firmer, 
and consequently more capable of reflecting the 
sound ; and, further, when these have become 
thick from exudation or are surrounded by thick- 
ened lung-structure. Conditions of this kind are 
tubercular, hemorrhagic, or pneumonic infiltra- 
tion, and intra-thoracic, solid tumors, which latter, 
partly by themselves, partly through compression, 
create a condition more favorable to transmission 
of sound. But in all these cases the lung-substance 
must be quite or almost void of air ; and there 
must be at least one larger bronchus inclosed in 
it, reaching even to the surface of the lungs. The 
hollow space must hold air, must be in free com- 
munication with the larynx, and must not be 
obstructed by a thick stratum of indurated paren- 
chyma. 

Collections of fluid in the pleural cavity, which 
otherwise create a weakening of the voice, cause 
a strengthening of it if they compress the lung 
so strongly that a large part lying near the w T all 
of the breast becomes void of air. The more 
superficially and the nearer to the thoracic wall 
such a compressed part of the lung lies, the 
stronger is the voice. Even a stratum of fluid 
from one to three inches in thickness, lying be- 



AUSCULTATION OF THE VOICE. 83 

tween the lungs and the thorax, does not injure 
the strength of the voice. 

Also, in case of hollow cavities, there should 
not exist between them and the thoracic wall a 
bad conducting medium. The more superficial 
these cavities are, the nearer they lie to the 
bronchial wall, and the thicker and harder are 
their walls, the stronger is the voice. Such hol- 
lows are tubercular, gangrenous, and apoplectic 
cavities ; likewise bronchial dilatation, and cavi- 
ties arising from abscesses. 

In old people the thoracic voice generally ap- 
pears stronger, for this reason, that the bron- 
chial cartilages have increas ed in thickness and 
hardness. 

If the ear be placed close to the thorax, 
the voice appears much weaker, as if coming 
from a greater distance; if it be pressed only 
lightly, it sounds much stronger, as if coming 
from nearer. 

Morbidly increased voice-sound, when in moder- 
ate degree, is difficult to be perceived and judged 
of, but its diagnostic value is essentially lessened 
by changes in the timbre, which are observed 
simultaneously with the vocal augmentation. 
These changes are bronchophony, segophony, 
the articulate and the metallic ringing voice. 

In bronchophony the voice manifests three 
different abnormal conditions : it is nasal, loud, 
and articulate. The voice always seems some- 



84 AUSCULTATION OF RESPIRATORY ORGANS. 

what nasal when morbidly augmented in strength. 
According to Wintrich, the production of the 
nasal sound occurs in the narrow or in the wide 
bronchial tubes, physically adapted to reflecting 
sound, if their walls by outward pressure, whether 
distorted in form thereby or not, are brought so 
near together that during vocal vibration they 
can quickly and tremulously touch each other 
and again separate. 

The causes of the morbid augmentation of 
the thoracic voice have been already explained. 
The strength of the vocal sound is also impor- 
tant here. The voice appears strongest in the 
vowels a and e, and weaker in o and u. There- 
fore, in examination of the thoracic voice, on 
corresponding points, the same syllables or words 
must be pronounced. 

Bronchophony becomes weakened by a feeble 
voice, by the walls of the bronchi and cavities 
being ill suited for reflection, by structures 
which are bad conductors lying between the ear 
and bronchi, and finally by large hollow spaces 
and by pneumothorax ; because then the voice 
acts upon too large a body of air. It may be- 
come destroyed in the before-named cases. The 
nasal voice may even be weaker in an affected 
part of a lung than the normal voice in the cor- 
responding point on the other side; for example, 
in pleuritic exudation. If then the bronchial res- 
piration is indistinct, the nasal voice is of greater 



AUSCULTATION OF THE VOICE. 85 

significance. The nasal voice can also be heard 
in simultaneously diminished fremitus pectoralis. 
Laennec's pectoriloquy is nothing more than 
strong bronchophony. 

The articulate and the nasal sounds are the 
characteristics of bronchophony. Of the causes 
of more distinct articulation we shall speak here- 
after. 

^Egophony, the goat-like or bleating voice, has 
the same signification as bronchophony, and be- 
comes strengthened or weakened through the 
same causes that it does. Wintrich presumed, 
after experiments, that the bleating voice arises 
in the same manner as the nasal, only with this 
difference, that in the bleating voice the trans- 
mission of the vocal tones is interrupted in a 
trembling manner. 

The articulation of the thoracic voice consists 
in this, that not only the tone of the voice arising 
in the glottis, but also the articulatory sounds 
produced in the mouth and throat, are heard 
within the thorax. Thereby the voice is free 
from the nasal and the bleating notes. Normally 
it appears, as in bronchophony, now and then in 
the inter-scapulary region, especially in strong 
whispering. The weaker degrees of the articu- 
late thoracic voice manifest themselves as whis- 
pering or lisping sounds. The hissing sounds of 
S, F, Sh, X, and Z, which, as syllabic endings, 
are distinguished a short time after the tones 

8* 



86 AUSCULTATION OF RESPIRATORY ORGANS. 

of the glottis are heard, are perceived as a whis- 
per after each syllabic sound, while the other 
articulate sounds are not to be heard during the 
glottis-tone, because they are surpassed in sound 
by it. The causes and signification of this non- 
vocal lisp are the same as in bronchial respiration 
and bronchophony. If this becomes stronger 
when the patient speaks in a whisper, then path- 
ological changes are certainly there; if not 
stronger, a decided opinion cannot be formed. 
But the non-vocal sound may be quite evident 
while the other bronchial indications are wholly 
undistinguishable ; then it has great diagnostic 
value; for example, in superficial caverns into 
which the larger bronchi open. 

In the highest grades of articulate thoracic 
voice not merely the resounding whisper is heard, 
but also the articulate tone during the glottis- 
tone; but this occurs so imperfectly that it is 
scarcely possible to separate vowels and conso- 
nants accurately and to understand words. These 
higher degrees of articulation manifest themselves 
in superficially situated cavities, and now and 
then in case of great thickening of the paren- 
chyma. In regard to the metallic ringing sound 
of the voice, as opportunity offered we have 
already spoken. 



RHONCUL 87 

D. The Frictional Bhonchi. 

In respiration there is a double movement of 
the lungs, first in a direction from above down- 
ward, in which the apices of the lungs are to be 
considered as fixed points, then in a horizontal 
direction from before backward, in which the 
posterior margins of the lungs remain immova- 
ble. Here the pulmonary pleura glides over the 
costal pleura. In costal respiration the horizon- 
tal movement is the stronger ; in abdominal 
respiration, on the contrary, the vertical move- 
ment is the stronger. 

If now the pleural membranes have become 
rough through false membrane or through growth 
of papillary connective tissue growths (pleuritis), 
the movement is indicated by a friction-sound. 
Knotlike growths on the pleura, especially of a 
scirrhous nature, or interlobular emphysema, 
which has made the superficial part of the lung 
rough, likewise create, though very seldom, fric- 
tion-sounds. The friction-sounds show manifold 
modifications : they are sometimes soft, some- 
times rough, sometimes creaking like the sound 
produced by rubbing together pieces of new 
leather. They can be imitated by so placing the 
middle finger of one hand upon the ear that the 
joint between the first and second phalanges lies 
before the external auditory passage, and then 
moving the nail or end of another finger over it. 



88 AUSCULTATION OF RESPIRATORY ORGANS. 

The friction-rhonchus is heard in inspiration or 
in expiration, or in both conjointly. Generally 
it is more frequent in inspiration, especially at 
its height. It ordinarily appears in an ascending 
and descending direction, seldom horizontally. 
Its extent is usually small ; weak friction-sounds 
often manifest themselves in a circumscribed 
manner over a space not exceeding the size of a 
silver dollar. If well marked, they can be felt 
by placing the hand over them. It is character- 
istic of them that they always follow at intervals, 
or in an interrupted manner. In pleuritis the 
friction-rhonchus is very often heard only for a 
brief period, and generally not at all. In the 
beginning of pleuritis, where the fibrinous de- 
posits are yet soft, or if, through effusion of fluid, 
the two pleural membranes are separated so that 
they cannot touch each other, finally, if the two 
pleural membranes have grown together, — a fre- 
quent result of pleuritis,— the frictional rhonchus 
is not heard. More frequently it appears after 
the absorption of exudation previous to adhe- 
sion. If the pleurisy exists at the top of the 
lungs or at their posterior inferior margins, 
which move but little, a friction-sound is rarely 
heard. If, partly from pain, partly from infil- 
tration and thickening of the lung-structure, 
one-half of the thorax moves but little, then 
likewise the friction-sound is not heard. Hence 
it is so seldom perceived in pleuro-pneumonia. 



AUSCULTATION OF COUGHING. 89 

In a later stage of pleuritis it often disappears, 
because the rough surfaces have become smooth 
through friction. It is usually observed only 
during a few days or weeks, occasionally for 
months, or even years, especially in tubercular 
pleuritis. When of long duration, it often 
changes place, dependent upon the position of 
the fluid, or upon the appearance of new points 
of pleuritic affection. Sometimes there is doubt 
whether the pleuritic friction is heard or not. If 
no interruption in expiration or in inspiration is 
perceptible, then it can only be the friction- 
rhonchus. 

E. Auscultation of Coughing. 

Coughing — that is, a loud-sounding expiratory 
rhonchus — is to be heard very loud over the 
larynx and trachea; over the thorax it yields no 
well-defined resonance. Its increased strength 
or weakness, its bronchophonic and metallic char- 
acter, have the same causes as the corresponding 
changes of sound in the voice. These properties, 
however, claim but little consideration, because 
the respiratory murmurs and the voice show them 
much more markedly. The brevity of the cough, 
and the oral reverberation surpassing all the rest, 
also increase the difficulty of auscultatory obser- 
vation. On the other hand, coughing makes 
many other auscultatory phenomena more evi- 
dent. Occasionally during coughing a distinct 



90 AUSCULTATION OF RESPIRATORY ORGANS. 

vesicular murmur is heard over the apex of a 
lung, which in ordinary respiration was not per- 
ceived ; and this, if other symptoms have already 
occurred, makes certain the supposition of tuber- 
culosis. Thus, a friction-sound, bronchial breath- 
ing, or metallic ring not unfrequently is first 
brought to observation by coughing. Vesicular 
rhonchi can be distinguished from frictional by 
this, that the former disappear after coughing 
and the consequent removal of secretion. 



CHAPTER II. 

AUSCULTATION OF THE ORGANS OF CIRCULATION. 

The auscultatory phenomena which are per- 
ceived over these organs may be divided into 
tones and murmurs, and are heard in the region 
of the heart or the arteries. 

A. Tones in the Region of the Heart 

In the region of the heart two tones are heard 
at intervals divided by a short pause. The first 
tone corresponds in time to systole, the second to 
diastole, of the heart. That the first tone is sys- 
tolic is proven by its being perfectly synchronous 
with the carotid pulse ; the radial pulse begins 
a little late, but its first half occurs exactly simul- 
taneously with the last half of the first tone. After 
the second tone follows a pause, which is longer 
than the pause between the first and second tones. 

In healthy persons, over the apex of the heart 
the first tone is often longer, louder, and more 
marked than the second; here the rhythm is a 
trochee, — ^; over the arterial ostia (origins), on 
the contrary, the second tone is longer, louder, 

(91) 



92 AUSCULTATION OF CIRCULATORY ORGANS. 

and more marked than the first, but its tone is 
that of an iambus, *—> — . The two tones vary 
also in regard to height. 

The extent to which they become audible over 
the thorax varies ; but they are always loudest 
over the apex. 

Causes of the Cardiac Sounds, — All tones in the 
circulatory organs arise from this, that a mem- 
brane passes from a state of less tension to a state 
of greater tension. It has been satisfactorily de- 
termined by experiment that the second tone 
arises from vibrations of the semilunar valves of 
the aorta and of the pulmonary artery. During 
systole these valves are applied to the arterial 
wall by the current of blood, and are absolutely 
free from tension ; during diastole, through the 
current of blood returning from the large arteries 
toward the ventricles, they become tense by de- 
grees until perfectly closed ; then they have the 
same high tension which the walls of the aorta 
and of the pulmonary artery possess. During di- 
astole there arise properly two tones, but they are 
heard as only one tone, because they arise simul- 
taneously. The systolic tone is produced by the 
vibrations of the auriculo-ventricular valves, but 
with this distinction, that the difference in tension 
in the venous valves is not so great as in the arte- 
rial. At the close of diastole the mitral and the 
tricuspid valves become tense through the contrac- 
tion of the auricle now commencing ; in systole 



SOUNDS JN THE CARDIAC REGION. 93 

they become still more so through the contraction 
of the ventricles, which have the same degree of 
tension as the aorta and pulmonary artery. Thus, 
while the semilunar valves pass from a state of 
relaxation during systole into the state of high 
tension of the aortic and pulmonary systems, the 
auriculo-ventricular valves at the close of diastole 
are tense, though in an inferior degree, and pass 
from this into another equaling that of the aorta 
and pulmonary arteries. In the latter case the 
difference in tension is less. But the intensity of 
the tones depends alone upon the difference exist- 
ing between the degrees of tension of the mem- 
branes; the absolute degree of tension is without 
influence. This explains the dullness of the sys- 
tolic tone. Bouillaud offers an additional expla- 
nation, viz. : that the first sound arises not only 
from the vibrations of the venous valves, but also 
from the striking of the self-opening semilunar 
valves on the arterial walls ; the second, from the 
striking of the auriculo-ventricular valves, to- 
gether with the vibrations of the arterial valves. 
According to this, there would arise eight tones; 
since every venous and arterial ostium (opening) 
of the heart produces two tones each. Scoda 
also taught these eight tones ; Kiwisch and Nega, 
the above-named four ; Bamberger believes that 
six tones are produced in the heart, in this way, — 
"that each ventricle of the heart produces a first 
tone of its own, and each artery produces a first 

9 



94 AUSCULTATION OF CIRCULATORY ORGANS. 

and second tone of its own. According to him, 
the first tone in the arteries has its cause in the 
suddenly increased systolic pressure in the arte- 
ries, and the consequent increase in the tension 
of the membranes. 

After the weighty objections which have been 
urged against all theories offered in regard to 
the origin of the cardiac murmurs, this alone 
holds its ground, that the diastolic murmur is 
produced only by the vibrations of the semi- 
lunar valves, and the systolic murmur by the 
vibrations of the venous valves. To support his 
opinion in regard to the origin of the first mur- 
mur in the arteries, Bamberger adduces the fact 
that under an unusual degree of pressure in the 
aortic system a systolic murmur is heard in the 
aorta abdominalis, in the crural artery, and even 
in the radial and tibial. This murmur cannot 
be transmitted from the heart, because the 
second murmur, which is almost always stronger 
than the first over the basis of the heart, is not 
heard in those arteries. But further proofs are 
necessary for establishing this opinion. 



SOUNDS IJST THE CARDIAC REGION. 95 



Abnormal Condition of the Cardiac Murmurs. 

Their rhythm may be changed in such- a way 
that the pause between the second and the next- 
occurring first murmur is only just as long as 
that between the first and the second murmur. 
Then the murmurs follow quickly upon each 
other. In like manner, the accent in the two 
murmurs may be equally strong ; or it may show 
over the apex and arterial openings a condition 
directly the reverse of its normal state-; so that 
at the apex an iambic and at the arterial open- 
ings a trochaic rhythm appears. However, these 
deviations occur in normal as well as in abnormal 
conditions of the organ of circulation : therefore 
they justify no diagnostic conclusion. 

The sounds also frequently show deviations 
from their healthy condition, which, however, may 
not amount to abnormal murmurs. They are not 
sharply defined; they become indistinct; and com- 
pared with the normal tones they are unlike the 
latter, without its being possible to say that they 
are changed in rhythm, strength, or height. The 
following may be mentioned as causes of these 
irregularities : augmented thickness or dimin- 
ished elasticity of the valves, decreased energy of 
the heart's action, and the sound being but ill con- 
ducted. Only in connection with graver symptoms 
can irregular murmurs enable us to decide upon 



96 AUSCULTATION OF CIRCULATORY ORGANS. 

definite changes, since they likewise appear in 
slight as well as in more important diseases of 
the heart. 

The purity of tone naturally authorizes the 
acceptance of the opinion that the semilunar 
and the auriculo-ventricular valves are in normal 
condition. 

There may also appear great differences in the 
height of the tone. The height and depth of the 
murmur depend upon the decrease and increase 
of the tension of the membranes. To this be- 
long the elevation and strengthening of the second 
aortic sound, of which more hereafter. 



Variations in the Strength of the Sounds. 

(1) Strengthening of the Systolic Sound. — This gen- 
erally appears in stenosis (narrowing) of the left 
venous opening. Stenosis usually occurs from 
perversion of form of the cusps of the mitral 
valve. The valve then does not project into the 
left ventricle in the form of a cylinder, as in the 
normal condition, but in the form of a funnel. 
Thus, during diastole less blood flows into the 
left ventricle than in the normal condition of the 
valve, because the mouth is narrowed. At the 
close of diastole the ventricle has not reached 
the degree of tension usual in the normal state; 
neither has the mitral valve. Now, the systole 



VARIATIONS IN STRENGTH OF SOUNDS. 97 

begins with its high normal degree of tension ; 
thus, the difference in degree of tension between 
systole and diastole is much greater in the mi- 
tral valve than elsewhere ; and, since the inten- 
sity of the murmur depends on the difference in 
degree of tension, therefore, in case of stenosis 
of the left auriculo-ventricular opening the first 
murmur is always augmented, provided there is 
not at the same time insufficiency of the aortic 
valves. 

In case of insufficiency of the aortic valves an 
inverse relation exists. Here the mitral valve 
at the close of diastole has already a high de- 
gree of tension ; this remains under the full 
pressure of the aorta, since the blood flows back 
into the left ventricle from the aorta. This de- 
gree of tension is only a little increased by the 
systole, since the ventricular pressure is only a 
trifle greater than the aortic pressure. The differ- 
ence in degree of tension of the mitral valve 
during the two phases of the action of the heart 
is thus very slight : therefore the first murmur 
in case of insufficiency of the aortic valves ap- 
pears dull or entirely obliterated. If the first 
sound be replaced by an abnormal murmur, 
which is not unfrequently observed, there exists 
simultaneously an insufficiency of the mitral 
valve, or there is roughness on the inner surface 
of the aortic valves. In case of insufficiency of 
the aortic valves the first sound is also dull, or 

9* 



98 AUSCULTATION OF CIRCULATORY ORGANS. 

it is wholly wanting, or it is replaced by a 
murmur. Apparently the first tone is pro- 
duced chiefly by the mitral valve, whilst in 
the same act the tricuspid plays only a second- 
ary part. Besides this, in simple aortic insuf- 
ficiency the right ventricle performs only a sub- 
sidiary part to the hypertrophied dilated left ven- 
tricle, so that it appears questionable whether 
so great a difference in degree of tension as is 
necessary to produce a murmur can occur in the 
tricuspid. In the same manner, in case of in- 
sufficiency of the mitral valve, not unfrequently 
no systolic tone is heard, but in its place a mur- 
mur, if the valve is atheromatous, or if adhesions 
of the valves with the ventricular walls or with 
the chordae tendineae have occurred. Together 
with the murmur a slight sound can also be 
heard. The murmur is either heard together 
with the sound (perisystolic murmur) or a short 
interval before the systolic sound (presystolic 
murmur). Here a part of the valve has still the 
power to produce a sound. 

(2) Augmentation of the Second Sound. — This 
manifests itself most frequently as augmentation 
of the second sound of the pulmonary artery, 
which Scoda first brought to notice as very im- 
portant in mitral insufficiency. This phenome- 
non appears near the left sternal margin, in the 
second or third intercostal space. In this case 
the second sound is heard loudest in the whole 



VARIATIONS IN STRENGTH OF TONE. 99 

cardiac region, and louder than in its normal 
state. Usually a slight throbbing is felt by the 
finger, and this is a visible pulsation of the pul- 
monary artery. The conditions necessary for 
the production of these phenomena are (1) hy- 
pertrophy of the right ventricle ; (2) an unusual 
facility for the transmission of sound : this takes 
place when the pulmonary artery lies close to 
the thoracic wall, or when it is separated from 
it by solidified lung-structure. Solidified lung- 
structure lies between the artery and the thoracic 
wall in case of tuberculosis ; and the pulmonary 
artery lies close to the thoracic wall in case of 
contraction of the left lung resulting from 
pleuritic exudation. In the latter case a very 
great displacement of the heart takes place at 
the same time, so that sometimes the site of the 
apex-impulse appears in the left axilla. Then, 
also, the pulmonary artery lies farther away from 
the left sternal margin ; viz., from If to 2 inches. 
This displacement of the heart is easily and 
with certainty established by the slight throb 
which the finger, when placed upon it, receives 
from the pulsating artery. In case of contrac- 
tion of the left lung, a loud and deep sound, 
limited in compass, is elicited by percussion 
along the left sternal margin. This also appears 
in case of pneumothorax; but the vesicular 
breathing renders sure the diagnosis of pulmo- 
nary contraction. The right lung is here hyper- 



100 AUSCULTATION OF CIRCULATORY ORGANS. 

trophied so that it extends beyond the left sternal 
margin, now and then reaching even to the region 
of the shoulder. This strengthening of the second 
tone of the pulmonary artery, together with the 
sound elicited by percussion just mentioned, is 
important in diagnosis of contraction of the left 
lung, but less so in diagnosis of cardiac disease. 
But if strengthening of the second tone of the 
pulmonary artery is caused by hypertrophy of 
the right ventricle, this symptom is very im- 
portant for diagnosis of hypertrophy, because 
it is the chief symptom of such a condition. 
Percussion gives us information in regard to dil- 
atation of the right ventricle, but not in regard 
to pure hypertrophy or the thickness of the mus- 
cular walls. The reason why in case of hyper- 
trophy of the right ventricle the second pul- 
monary sound is strengthened, is easy to be seen. 
At the end of diastole, when the closure of the 
semilunar valves is complete, these have the 
same degree of tension as the pulmonary walls 
or those of the right ventricle. But in case of 
hypertrophy of the right ventricle its increased 
power creates a greater degree of tension of the 
right ventricle, which is also propagated to the 
walls of the pulmonary artery, through the in- 
creased pressure of the blood forced out from 
the heart. The semilunar valves have also to 
endure the same pressure, which is. greater than 
in normal conditions. In systole they float or hang 



VARIATIONS IN STRENGTH OF SOUND. 101 

without any tension, and in diastole their tension 
is greater than usual. The difference in tension 
is thus greater than before, and this occasions 
the strengthening of the second sound of the 
pulmonary artery. If the conditions of trans- 
mission of sound are normal or less favorable, 
and the augmentation of the second pulmonary 
sound is permanent, then it is safe to decide 
upon hypertrophy of the right ventricle, since 
without this no permanent augmentation is pos- 
sible. 

Strengthening of the second sound of the aorta 
occurs in hypertrophy of the left ventricle when 
this is not caused by valvular defect. These de- 
fects are insufficiency and stenosis (contraction) 
of the aortic valves. In the first case a murmur 
of the second aortic tone is always heard. Mod- 
erate degrees of stenosis are almost always accom- 
panied by insufficiency, and manifest together 
with the systolic a diastolic murmur also. High 
degrees of stenosis, whether accompanied by a 
small degree of insufficiency or not, give during 
diastole either a weak, short tone, or a weak 
murmur; most frequently no distinct manifesta- 
tion of sound. The valves here form adhesions 
in such a tnanner as to leave but a small central 
opening, and thereby are so greatly thickened 
that they have become almost immovable and 
without vibratory power. 

The strengthening of the second aortic tone is 



102 AUSCULTATION OF CIRCULATORY ORGANS. 

only observed in case of hypertrophy of the left 
ventricle, and then indeed only when this is oc- 
casioned by abnormally increased obstructions 
in the peripheral part of the aortic system. The 
place best adapted for their auscultation is at the 
upper part of the second costal cartilage, at the 
right of the sternum. "When the obstructions 
in the peripheral part of the aortic system are 
increased, thus opposing the emptying of the 
left ventricle, the tension of the aortic system is 
thereby increased. Through the regurgitation 
of blood during diastole, the semilunar valves 
of the aorta also attain this high degree of ten- 
sion, and thereby the difference in the tension 
of the valves during systole and diastole is in- 
creased. But the greater the difference the 
louder the tone; hence the strengthening of the 
second aortic tone. The absolute degree of 
tension of the valves, as we have seen, is higher 
in diastole than normal:; and since the height of 
the tone depends upon the absolute final degree 
of tension, therefore at the same time the second 
tone also appears higher. It (the heightened 
tone) is also often united with a ringing timbre, 
for which no explanation has yet been given. 
There are two cases which the obstructing in- 
fluences in the peripheral part of the aortic sys- 
tem heighten, viz., atheromatous changes and 
obstructions to circulation in the kidneys. In 
sclerosis or atheroma the tunica intima, or in- 



VARIATIONS IN STRENGTH OF SOUND. 103 

most membrane, of the small arteries becomes 
thickened, so that they are not only narrowed, 
but may even become closed. The sclerosis or 
atheroma is particularly frequent in persons of 
advanced age. Renal diseases which obstruct 
the circulation are atrophy, thickening of the 
capsules of the glomeruli, and interstitial nephri- 
tis, in which the vasa efferentia are compressed 
by the thickened connective tissue. The height- 
ened tension of the aortic system can be felt in 
both cases at the pulse. In order to examine the 
walls of the arteries and the pulse in their greatest 
possible extent, all four fingers should be laid 
together upon the artery. By pressing the finger- 
points upon it, we can hinder or wholly check 
the action of the pulse. The greater the pressure 
necessary to do this, the higher is the tension in 
the aortic system. 

Weakness and Absence of the Second Aortic Tone. — 
These are observed (1) in stenosis of the aortic 
valves, as before elucidated. (2) In insufficiency 
of the aortic valves. In the latter case a mur- 
mur is not always heard, but there is often a 
distinct though weak diastolic tone. Then 
slight changes arise in the valves in which 
they still have tone-producing vibratory power. 
(3) In a high degree of stenosis of the left au- 
riculo-ventricular opening, or in insufficiency 
of the mitral valve, the second sound often 
becomes inaudible at the cardiac apex. In 



104 AUSCULTATION OF CIRCULATORY ORGANS. 

stenosis, less blood flows from the left auricle 
into the left ventricle; thus the latter, during 
systole, can only force less blood into the 
aorta. Hence the degree of tension in the 
aorta becomes less, and also that of the aortic 
valves. The result of this is that the second 
aortic sound becomes weaker and can no longer 
be transmitted so far as normally, — that is, not so 
far as the apex of the heart. The same occurs 
in mitral insufficiency. When the cusps of the 
mitral do not close, less blood passes into the 
left auricle; and hence during systole there is 
less blood sent into the aorta. 



Scope of the Cardiac Sounds. 

The sounds of the heart, in most cases, are 
heard only over the heart and in its immediate 
vicinity. At a greater distance they are sur- 
passed in sound and concealed by the respiratory 
murmur. In all cases of augmentation of the 
cardiac sounds, they are heard over a more ex- 
tended space; the same obtains in conditions 
favorable for transmission of sound. In persons 
with narrow and emaciated thorax, or where 
there is thickening of the lung-structure in the 
region of the heart, the heart-tones may often 
be heard over a larger space, anteriorly as well 



SCOFF OF THE CARDIAC SOUNDS. 105 

as posteriorly, on the thorax. It is especially 
worthy of notice that they are still heard loud 
in case of extensive tubercular deposit in the 
apices of the lungs in the infra-clavicular region. 
The distended stomach also causes the heart- 
tones to sound over a larger space than normally. 

The metallic click is a rattling systolic sound 
(not to. be confounded with the ringing systolic 
sound) which is sometimes heard over the ven- 
tricles and apex of the heart. It sometimes ap- 
pears accompanied with a slight rattling sound, 
and is said to be caused by the vibrations of the 
thoracic wall. 

Division of the Cardiac Sounds. — This arises thus, 
that one sound is composed of several impulses 
of sound (tum-tr-rum, or tum-tr-r-rum). In this 
form the first tone appears as well as the second, 
the latter, however, more frequently; both ap- 
pear over the pulmonary artery and aorta as w^ell 
as over the ventricles. This phenomenon, though 
brief in duration, is still frequently observed. 
In a consumptive boy, Scoda heard it only a 
few days before death. Since it appears in the 
normal condition of the heart as well as in case 
of valvular defect, as proved by autopsy, no 
diagnostic value can be attached to it. It is also 
observed in the beginning of pericarditis, but it 
authorizes no decisive opinion in regard to this 
disease. No better explanation has been offered 
up to the present time. Williams and Scoda 

10 



106 AUSCULTATION OF CIRCULATORY ORGANS. 

trace the division of the first tone to the irregular 
contraction of the ventricles. The division of 
the second tone is explained by Bamberger in 
this way, — that in systole the pulmonary artery 
and aorta instead of one single contraction make 
several spasmodic contractions, and thereby the 
blood is driven against the valves, which causes 
a repeated tension and sounding of the same. 
As an analogy, he states that a weakened muscle, 
under the influence of the will, does not contract 
with a single motion, but with several spasmodic 
impulses. This opinion he sustains by the cir- 
cumstance that the division of the cardiac sounds 
is observed in patients affected with diseases of 
opposite natures, in whom a diminution of the 
vital tone of the artery might readily be in- 
ferred. 

B. Murmurs in the Cardiac Region. 

The causes of the murmurs in the cardiac 
region are : 

(1) Inequalities on those surfaces of the peri- 
cardium which are turned toward each other. 
These are produced by fibrinous deposit in case 
of pericarditis, less frequently by growths of 
connective tissue or by chalky deposits, very 
seldom by tubercles or cancerous indurations. 

(2) Inequalities on the surfaces of the valves 
which are turned toward the current of blood. 



MURMURS IN TEE CARDIAC REGION. 107 

Inequalities on the arterial walls and on the 
inner surfaces of the ventricles create no mur- 
mur. Inequalities on the valves are connected 
with endocarditis, or the so-called atheromatous 
process, with hypertrophy of the valves, and, 
less frequently, with fibrinous deposits from the 
blood. 

(3) Structural changes which lead to insuffi- 
ciency or stenosis (narrowing) of a valve. In- 
sufficiency is produced by contraction, thicken- 
ing, induration, and by perforation of the valves, 
by excrescences upon them, and by their adhe- 
sion to the walls of the arteries: Stenosis is 
most frequently produced by adhesion of the 
valve-cusps. The real cause of the murmur 
here lies in the changes of the valves; yet insuffi- 
ciency and stenosis can also create such murmurs 
through changes in the current of blood. 

(4) Communications between the cardiac cavi- 
ties or vessels, as between the aorta and pulmo- 
nary artery, by the remaining open of the fora- 
men ovale, and defect in the partition dividing the 
cardiac cavities. Communications of this kind, 
when slight, produce no murmurs ; when greater, 
loud continuous murmurs arise, which are heard 
diffused over the whole cardiac region. 

(5) Changes in the vibratory power of the 
valves and arteries very often give rise to mur- 
murs. Such changes, which apparently result 
from diminution in the tone of the valves and 



108 AUSCULTATION OF CIRCULATORY ORGANS. 

arteries, and from diminution in the energy of 
the action of the heart, appear in acute febrile 
diseases, acute exanthema, articular rheumatism, 
pneumonia, febris puerperalis, typhus, and dis- 
eases arising from blood-poisoning; they likewise 
appear in an semi a, chlorosis, leucaemia, scorbu- 
tus, tuberculosis, and morbus Brightii. Bamber- 
ger calls these accidental murmurs. Structural 
changes situated at a distance from the valves 
produce no murmurs. To these belong excres- 
cences, thrombi between the trabecula, eccentric 
croppings out of the cardiac wall near the apex, 
etc. For the production of murmurs a certain 
velocity in the current of blood is necessary. 
The greater the velocity of the blood-current, the 
louder the murmur, and vice versa. Thus, even 
in case of structural change, murmurs may dis- 
appear during or toward the close of chronic 
disease. Three essential particulars are distin- 
guished in the abnormal murmurs: (1) the time, 

(2) the place where they are most strongly heard, 

(3) their character. 

We have four diagnostic means of deciding 
the time of a murmur : (1) the apex-impulse ; 
this occurs exactly with the systole. Thus 
every phenomenon which coincides with it is 
called systolic. (2) The carotid pulse; this is 
almost perfectly synchronous with the systole. 
(3) The radial pulse ; the first half of this coin- 
cides with the systole, its second half follows the 



DIASTOLIC MURMURS IN CARDIAC REGION. 109 

systole. All that coincides with the carotid 
pulse, or with the beginning of the radial pulse, 
belongs to the systole. (4) The intervals ; the 
interval between the second and the succeeding 
first cardiac sound is longer than the pause be- 
tween the first and the second sound. Every 
phenomenon which follows directly after the long 
interval is synchronous with the systole. The 
apex-impulse is most readily employed as a diag- 
nostic means. If it is moderately strong the 
stethoscope is somewhat raised during each sys- 
tole. The carotid pulse stands next to the apex- 
impulse as a diagnostic means ; the radial pulse is 
not sufficiently exact. It requires much practice 
to make the intervals available in diagnosis. A 
murmur is called diastolic when it is separated 
by a distinct pause from the apex-impulse or 
from any other systolic phenomenon. Gendrin 
distinguished in addition an instant of time be- 
fore and after S} T stole and diastole, as presystole 
and prediastole, perisystole and peridiastole, and 
named the murmurs correspondingly. Such a 
distinction is, however, quite unessential, and 
difficult to carry into practice. 

Diastolic Abnormal Murmurs. — Every diastolic 
abnormal murmur alone authorizes the inference 
of structural changes in the valves or pericar- 
dium; every systolic murmur does not do so. 
Diastolic murmurs are consequently of much 

10* 



HO AUSCULTATION OF CIRCULATORY ORGANS. 

more importance in diagnosis of diseases of the 
heart. 

We will adopt Traube's method, and divide 
the diastolic murmurs into two kinds; viz., the 
simple and the modified diastolic murmur. 

(1) The simple or pure diastolic murmur is 
separated from the preceding and succeeding 
systole by a distinct pause ; the whole may thus 
be represented by these initial letters : 

S. P. D.M. P. IS. ! 



It is heard (a) in case of insufficiency of the 
aortic valves, either alone or with a systolic 
murmur. The latter arises from inequalities on 
that surface of the valves which is turned toward 
the ventricle, over which flows the systolic blood- 
current. When one cusp of the valve still pos- 
sesses vibratory power, a distinct tone appears 
in diastole, to which a short, occasionally very 
weak, murmur follows as a complementary 
sound. 

S. P. D. M. P. IS. 



c.s. 

(b) The pure diastolic abnormal murmur ap- 
pears if there is perforation of the mitral valve, 
even when the blood flows with unimpeded cur- 
rent/ In diastole the blood flows not merely 



DIASTOLIC MURMURS IN CARDIAC REGION. \\\ 



through the left auriculo-ventricular opening, but 
also through the perforation into the left ventricle ; 
from the latter current the murmur arises. Such 
perforations are first formed in the surface of 
the valve by the atheromatous process ; the 
blood is then forced through this perforation 
into the interior of the valve, causing the 
opposite side to protrude, and finally to burst. 
In this way valvular aneurism first arises. 

(2) The Modified Diastolic Abnormal Murmur. — 
This murmur blends with the succeeding systolic 
tone without interval, either occupying (a) the 
whole diastole, or (b) appearing only at the close 
of diastole. 

S 



S.P.D.M 

8. P.D.M. 



b. 



S. 



In the second case the diastolic murmur ap- 
pears as if it were a premature stroke of the 
systolic tone. On this account many have de- 
noted it as a pres3 r stolic tone. While the simple 
or pure diastolic murmur appears in case of insuf- 
ficiency of the aortic valves, the modified mur- 
mur shows itself in case of stenosis (contraction) 
of the left auriculo-ventricular opening. It is 
very essential, in prognosis and treatment, to dis- 
tinguish between these two diseases of the heart. 

Where there is insufficiency of the aortic valves, 
life may be prolonged for a considerable time ; 



112 AUSCULTATION OF CIRCULATORY ORGANS. 

when, however, death ensues, it is sudden, result- 
ing from cerebral apoplexy ; where there is steno- 
sis of the left auriculo-ventricular opening, life is 
continued for but a brief period ; death, however, 
is not sudden, as in the preceding case. In the 
latter disease digitalis has a very beneficial effect, 
but not in the former. The reason why in the 
former disease the first modified diastolic murmur 
is heard, and in the latter the second, is as follows : 
Where there is insufficiency of the aortic valves, 
during diastole the blood flows from two sides 
into the left ventricle, viz., from the left auricle 
and from the aorta. In this way the left ventricle 
becomes filled sooner than when the valves, prop- 
erly closing, shut off the current from the aorta, 
and the ventricle sooner reaches that degree of 
tension which normally appears only at the close 
of diastole. It must necessarily follow that the 
current from the left auricle will cease sooner, 
because the aortic current is the stronger. But 
the aortic current also ceases before the close of 
diastole, because the left ventricle has already 
attained the tension of the aortic system before 
the completion of diastole. But when the cur- 
rent of blood from the aorta ceases, then the 
murmur also ceases ; hence the distinct pause 
between the diastolic murmur and the next sys- 
tole. Where there is stenosis of the left auriculo- 
ventricular opening, the opposite is the case. 
Since through the narrowed opening less blood 



DIASTOLIC MURMURS IX CARDIAC REGION. H3 

flows from the left auricle into the left ventricle 
than in its normal state, it follows that at the 
close of diastole the left ventricle has fallen far 
short of reaching its normal fullness and tension. 
At the beginning of diastole the current into the 
left ventricle is of uniform rapidity, because the 
latter is without tension and empty ; but at the 
end of diastole the contraction of the left auricle 
occurs, thereby the movement of blood is acceler- 
ated. Thus the murmur produced at the begin- 
ning of diastole continues until its close, and then 
becomes stronger. But if at the commencement 
of diastole the current of blood is too slight, then 
the murmur does not arise at first, but only at the 
close of diastole. This causes the second species 
of the modified diastolic murmur. This so-called 
presystolic murmur is also heard when there are 
inequalities upon those surfaces of the mitral 
valve which are turned toward the auricular 
current of blood. If, where there is stenosis of 
the left auriculo-ventricular opening, the hand be 
laid upon the point of the apex-impulse, a diastolic 
tremor or trill is felt, — the so-called presystolic 
cat-purring sound (fremissement cataire). Some- 
times it is systolic, in which case it arises from 
insufficiency of the mitral valve existing at the 
same time. It is seldom both systolic and dias- 
tolic. 

Finally, diastolic abnormal murmurs also arise 
from insufficiency of the valves of the pulmonary 




114 AUSCULTATION OF CIRCULATORY ORGANS. 

artery. This affection is of the rarest occurrence. 
It is usually congenital. In adults, insufficiency 
may arise from the occurrence of fenestration or 
perforation of the valves. On the pulmonary 
valves, particularly in old persons, the places may 
/ be seen where the valvular edges 

have been in contact, — the so-called 
lunula, as represented by a a in the 
diagram, b representing the corpus 
Arantii. The closing of the valves occurs by 
contact of their surfaces, not merely by that of 
their edges, and hence it is much more effectual. 
If the aortic valves only closed by contact of their 
edges, then almost every time that a heavy weight 
were lifted insufficiency of the aortic valves 
would arise, because the pressure in the aortic 
system would thus be increased. If now the 
perforations or abrasions are within the lunufe, 
the closing of the valves is not at all disturbed. 
But if these are close to the edge of the lunulse, 
then the opening is not covered by the opposite 
margin of the adjacent valve as soon as the 
pressure in the pulmonary aortic system is in- 
creased, and thus the valves become stretched or 
expanded. Then the blood regurgitates through 
the perforated valve from the pulmonary artery 
into the right ventricle. 

Traube say s that he also saw insufficiency arise 
in a case where a heightened pressure had ex- 
isted for a long time in the pulmonary arterial 



DIASTOLIC MURMURS IN CARDIAC REGION. H5 

system. He explains this as follows: "Through 
long-heightened pressure the pulmonary artery 
becomes enlarged, its opening also increases in 
caliber, and the valves become more expanded, so 
that only their margins come in contact. One 
of these, under the pressure of the superincum- 
bent blood, gives way readily, and the insuffi- 
ciency is thus created." 

In case of stenosis in the right auriculo-ven- 
tricular opening, it is to be accepted a priori that 
the same murmurs must be heard as in stenosis 
of the left auriculo-ventricular opening ; but this 
affection has not been observed singly, and there- 
fore its symptoms are not exactly known. Ste- 
nosis of the tricuspid valve always appears in 
connection with insufficiency of the valve; but 
there is seldom a high degree of stenosis. The 
foundation of insufficiency is always laid in foetal 
life through endocarditis of the tricuspid valve. 
Why this particular valve, rather than any other, 
is subject to endocarditis during foetal life, is 
unknown. Death ensues either before birth or 
soon afterward ; in extremely rare instances the 
subjects may reach adult age. Still, insufficiency 
of the tricuspid valve seldom exists by itself: as 
a rule, this valve is affected with endocarditis and 
atheroma after the other valves are already 
attacked. Hence insufficiency of the tricuspid 
valve always appears in combination with other 
valvular defects, particularly those of the mitral 



116 AUSCULTATION OF CIRCULATORY ORGANS. 

valve. Where there is insufficiency of the tri- 
cuspid valve, a distinct, loud, systolic murmur is 
heard, varying in extent, which is loudest on the 
tricuspid valve, that is, on the lower part of the 
sternum, on a level with the fifth costal cartilage. 
Where there is moderate hypertrophy and dila- 
tation of the right ventricle, the murmur exhibits 
its greatest intensity at the right of the sternum, 
on a level with the fifth costal cartilage. Now 
and then, together with the murmur, a still more 
distinct systolic tone- may be heard. But this 
murmur can proceed only from the mitral or 
aortic valves. If auscultation be directed farther 
to the right of the tricuspid valve, on the same 
level with it, the aforesaid propagated murmurs 
are no longer to be heard there, while the sounds 
of the tricuspid valve are still distinctly audible, 
however weak they may be. In case a murmur 
originate from the tricuspid, then it becomes 
less and less audible as we proceed toward the 
right, and when it disappears, then we hear no 
sounds from any other source. In diastole a 
more or less distinct sound is heard if a slight 
degree of stenosis exists in connection with in- 
sufficiency. If a greater degree of stenosis exists, 
especially if there are considerable inequalities 
on the valve, a diastolic murmur is heard. But 
if the current from the auricle into the ventricle 
is weak, then neither normal nor abnormal sound 
is to be heard. The diastolic murmur of aortic 



DIASTOLIC MURMURS IN CARDIAC REGION. H7 

insufficiency is also generally heard very distinctly 
over the tricuspid valve. But it is heard loudest 
over the aortic valves; and, besides, the other 
symptoms of aortic insufficiency (strengthened 
apex-impulse, quick pulse) are sufficiently distinct 
to diagnosticate the latter affection. 

The second pulmonary aortic tone is generally 
weakened, the more so the less the ventricle is 
hypertrophied. When there is considerable hy- 
pertrophy, the second pulmonary arterial tone is 
not weakened; it may, indeed, be temporarily 
strengthened. Also in case of considerable ste- 
nosis, the character of the second pulmonary arte- 
rial tone is influenced by the degree of hyper- 
trophy of the right ventricle. Where doubt 
exists in regard to the site of insufficiency, the 
absence of the increased sound speaks in favor 
of its being the tricuspid valve. 

The venous pulse is characteristic of insufficiency 
of the tricuspid valve. This appears in the jugu- 
lar veins, particularly on the right internal jugu- 
lar vein. The pulse is systolic, and both palpable 
and visible, exactly like the pulse of a large 
artery. The systolic impulse of the right ven- 
tricle is transmitted with the blood, which flows 
through the insufficiently closed auriculo-ven- 
tricular opening into the auricle, and causes the 
blood of the latter to regurgitate into the jugular 
veins. By this means the veins become so dilated, 
and their caliber so increased, that their valves 

11 



118 AUSCULTATION OF CIRCULATORY ORGANS. 

become insufficient, and thus a current of blood 
flows from below upward. A systolic undula- 
tion also appears on the jugular veins, particu- 
larly on the external jugular vein. The impulse 
is either communicated to the vein from the 
carotid artery, or it is derived from the heart. In 
great fullness and strong contraction of the right 
ventricle the systolic impulse is communicated 
by means of the tricuspid valve to the auricular 
stream of blood, and through the closing venous 
valves to the blood in the jugular veins. Even 
under normal conditions a slight regurgitation 
takes place. 

Pulsation is easily distinguished from undula- 
tion. If the vein be compressed, then the part 
below the point of compression becomes dilated. 
In undulation no dilatation takes place, even 
though the movement still continue. 

The Systolic Abnormal Murmurs, — Structural 
change in the organs of circulation cannot be 
unconditionally inferred from systolic, as it can 
be from diastolic, murmurs ; indeed, in by far the 
greater number of cases the former occur with- 
out structural change. 

The causes of these are : 

(1) Insufficiency of the auriculo-ventricular 
valves. 

(2) Stenosis of the arterial mouths or openings. 

(3) Roughness on those surfaces of the valves 
which are turned toward the current of blood. 



SYSTOLIC MURMURS IN CARDIAC REGION. H9 

(4) Systolic murmurs appear without structural 
change where there is disease of blood, as in 
chlorosis and anaemia ; it matters not whether 
these latter arise from sexual irregularities or 
from disturbances of nutrition in consequence of 
Bright' s disease, tuberculosis, carcinoma of the 
alimentary passages, or from other diseases. 
Further, the systolic murmurs appear in connec- 
tion with most acute febrile diseases, — in typhus, 
puerperal fever, acute exanthema, and acute 
articular rheumatism. A satisfactory cause for 
the appearance of the murmurs in the latter two 
cases has not as yet been given. Bamberger 
assumes that they have their origin in some 
change, usually a diminution of the vital tone of 
the valves and inner arterial coatings; further, 
in perverted cardiac contraction and irregular 
movement of the blood, and the influence of 
these upon the tension of the valves and arterial 
coatings. That the systolic murmurs can be pro- 
duced by the arterial walls is proved in all cases 
where these murmurs are stronger in the arteries 
than in the heart; for example, in the carotid 
artery. But if they are loudest in the heart, then 
they cannot be produced in the arteries, but must 
arise in the heart, through change in the tension 
of the valves. Perhaps great influence is here . 
exerted by the papillary muscles, which produce 
the tension and fixation of the valves. A relax- 
ing of these papillary muscles is followed by a 



120 AUSCULTATION OF CIRCULATORY ORGANS. 

similar diminution in the tension of the valves ; 
but the causes of this relaxing, with the excep- 
tion of that of fatty degeneration, are as yet 
unknown. 

It is of great importance to be able to desig- 
nate the place where a murmur appears loudest. 

In the cardiac region auscultation must always 
be made in four places. 

(1) The Apex of the Heart — This can easily be 
determined by the apex-impulse, and, if this is 
not well marked, by percussion. 

(2) The lower end of the sternum, between the 
fifth costal cartilages. This place corresponds to 
the right auriculo-ventricular opening. 

(3) The third left costal cartilage near the ster- 
num. The mouth of the pulmonaiy artery and 
its valves lie close to the margin of the sternum, 
in the middle of the second left intercostal space. 
If the heart lies lower, the pulmonary valves are 
to be sought for in the third left intercostal space. 
On the third left costal cartilage the sound, as a 
rule, is more evident than in the second left 
intercostal space. The left auriculo-ventricular 
opening and the mitral valve correspond to the 
third left costal cartilage. But this place is ill 
suited for auscultation of the parts named, partly 
because the pulmonary valves are too near, partly 
because here a thick stratum of lung-structure, 
which is unfavorable to conducting the sound, 
lies over the heart. The sound of the mitral 



SYSTOLIC MURMURS IN CARDIAC REGION. 121 

valve is heard loudest over the apex of the heart, 
because the apex, lying close to the thoracic wall, 
transmits the sound to it ; for the cardiac struc- 
ture is a better conductor of sound than the 
normal pulmonary tissue. 

(4) The second right intercostal space, close to 
the sternum. The mouth and the valves of the 
aorta lie on a level with the third left costal car- 
tilage at its point of union with the sternum, but 
are covered with the conical commencement -of 
the pulmonary artery. The ascending aorta, in its 
course to the right and upward, lies exactly behind 
the sternum, but from the third to the seventh rib 
it reaches a little beyond the right sternal margin. 
The arch of the aorta coincides with the first in- 
tercostal space, thence it turns backward and to 
the left, and downward as the descending aortal 
The aortic valves are not susceptible of ausculta- 
tion at the third left costal cartilage, but they are 
so at the second right intercostal space, close to 
the sternum, because at the former place the 
sounds of the pulmonary valves would be mingled 
with those of the aorta. 

It is very important to distinguish between 
these places in auscultation. But it does not 
follow that structural change exists where the 
murmurs are heard loudest. In case of insuffi- 
ciency of the aortic valves the diastolic murmur 
is not unfrequently loudest at the fourth or fifth 
rib, at the right of the sternum, thus being 

11* 



122 AUSCULTATION OF CIRCULATORY ORGANS. 

louder there than in the second intercostal space. 
As far as the third or fourth rib the margins of 
the lungs lie close together between the heart, 
the arterial mouths, and the thoracic wall; thence 
they gradually recede, and leave the heart uncov- 
ered. But the sound is conducted downward 
through the cardiac structure better than it is 
forward through the lung-tissue. Therefore the 
murmur is loudest below the fourth rib, where 
there is no longer any lung-structure between 
the heart and the thoracic wall. Where there 
is increase in the volume of the lungs, so that 
they almost completely cover the heart, the 
sounds are feebly audible, even when the action 
of the heart is morbidly augmented, Further, 
the murmurs are most readily transmitted along 
with the current of blood which has produced 
them. In case of insufficiency of the aortic 
valves the current returns into the left ventricle. 
This also serves to explain why the sound is 
not unfrequently loudest on a level with the 
fourth or fifth costal cartilage, or over the ster- 
num. 

In case of stenosis of the mouth of the aorta 
the murmur is produced by the current from the 
left ventricle into the aorta; therefore it is always 
heard loudest in the second right intercostal 
space. 

As rules we may adopt the following : 

(1) In all cases of structural change in the 



3IUR31URS IN THE CARDIAC REGION. 123 

mitral valve, the sound is loudest at the apex of 
the heart, 

(2) In case of structural changes in the tricus- 
pid valve, it is loudest at the lower end of the 
sternum, on a level with the fifth costal cartilage. 

(3) In case of structural changes in the aortic 
valves, it is loudest in the second right intercostal 
space. 

(4) In case of structural changes in the pulmo- 
nary valves, it is loudest in the second or third 
left intercostal space. 

Timbre of the Murmurs. — The cardiac murmurs 
are very different in tone. Formerly many kinds 
were distinguished, and, in France especially, 
great diagnostic value was attached to them. 
But this matter of timbre is of little importance 
in comparison with that of time and place of the 
tone. The pericardiac friction-murmurs can in 
most cases be recognized by their character : they 
are usually rubbing, rasping, and harsh, as in 
pleuritic friction. Sighing, whistling, filing mur- 
murs almost always arise from structural changes 
in the valves. The murmurs which accompany 
anaemia, chlorosis, and acute diseases are almost 
always of a blowing character. The so-called 
musical murmurs are recognized less by their 
timbre than by their being heard at a distance. 
The diastolic murmur which accompanies insuf- 
ficiency of the aortic valves often resembles a 
mild trumpet-tone, and, to the great annoyance of 



124 AUSCULTATION OF CIRCULATORY ORGANS. 

the patient, is often to be heard at a distance of 
from one to two feet, particularly at night. The 
murmurs which accompany other affections of 
the valve are not so loud, because in none of them 
are the pressure and the difference in tension so 
great. However, occasionally, in case of insuffi- 
ciency of the mitral valve, the pressure may be 
as great, or even greater. We are by no means 
authorized to infer greater roughness on the 
valves from the rasping murmurs than we are 
from others. They even appear in case of chlo- 
rosis and anaemia, and disappear with them. 
Temporary disappearance is also characteristic of 
murmurs unaccompanied by structural changes. 
Other characteristics wdiich distinguish them are 
as follows : 

They are usually heard over 'a large space, even 
when feeble, and in that case they seem to be a 
part of the normal first sound. In the carotid 
artery a systolic blowing is likewise to be heard, 
and on the jugular vein a loud nun-murmur, or 
" bruit de diable." The latter very seldom appears 
in case of defective valves. And, finally, the 
symptoms of consecutive hypertrophy and dilata- 
tion are absent. 

Diagnostic Value of the Murmurs. 

(1) A systolic murmur, which is loudest at the 
apex of the heart, or a little farther above, 
toward -the left nipple, indicates — 



MURMURS IN THE CARDIAC REGION. 125 

(a) Insufficiency of the mitral valve when the 
second tone of the pulmonary artery is augmented 
and dullness of the cardiac murmur increases 
toward the right (indicating hypertrophy of the 
right ventricle). The absence of the first and 
second sounds at the apex is also especially im- 
portant for diagnosis of insufficiency of the mitral 
valve, as previously shown. 

(b) Roughness on that surface of the mitral 
valve which is turned toward the ventricle. In 
this case the increase of cardiac dullness, and the 
augmentation of the second sound of the pulmo- 
nary artery, are wanting. This may be distin- 
guished from the anemic, or, as Bamberger has 
more appropriately named those murmurs which 
arise without structural change, the accidental 
murmurs, by this, that it is only to be heard at 
the apex or a little above on the left side. 

(c) It may arise unaccompanied by structural 
change, being accidental.. 

(2) A diastolic murmur, which is loudest on 
the places named, indicates — 

(a) Stenosis of the left auriculo-ventricular 
opening when the symptoms of hypertrophy of 
the right ventricle are present. In this case a 
diastolic murmur may be felt, extending from the 
apex of the heart to the nipple, arising from ac- 
companying insufficiency of the mitral valve ; in 
rare instances a systolic murmur results from the 



126 AUSCULTATION OF CIRCULATORY ORGAXS. 

same cause. The pulse has a low wave, pulsus 
parvus. 

(b) Roughness on that surface of the mitral 
valve which is turned toward the auricle, if the 
signs of hypertrophy of the right ventricle are 
wanting. 

(3) A systolic murmur, which is loudest on the 
second right intercostal space, close to the ster- 
num, indicates — 

(«) Stenosis of the aortic mouth, when the 
cardiac dullness and the point of the apex-im- 
pulse extend beyond the left mammillary papil- 
lae; that is, if there is hypertrophy of the left 
ventricle. 

(b) Roughness on those surfaces of the valves 
which are turned toward the ventricle. In this 
case the signs of hypertrophy of the left ven- 
tricle are wanting. 

(c) It may be accidental. 

(4) A diastolic murmur, which is loudest in 
the second right intercostal space, indicates — 

Insufficiency of the aortic valves. In this case 
the diastolic sound is wanting in the carotid 
arteries, the signs of hypertrophy of the left 
ventricle are present, the pulse has a high, short 
wave, pulsus celer. 

(5) A systolic murmur, which is heard strong- 
est at the inferior end of the sternum, on a level 
with the fifth costal cartilage, indicates — 



MURMURS IN THE CARDIAC REGION. 127 

(a) Insufficiency of the tricuspid valve, when 
at the same time the cardiac dullness is consider- 
ably increased toward the right (indicating dila- 
tation of the right auricle, and hypertrophy and 
dilatation of the right ventricle), and a systolic 
pulsation in the jugular vein is palpable and 
visible. 

(b) Roughness on that surface of the tricuspid 
valve which is turned toward the ventricle, in 
case the above-named symptoms are wanting. 
Insufficiency and roughness of the tricuspid 
valve very seldom occur; usually, the systolic 
murmur is 

(c) Of an accidental nature. 

(6) A diastolic murmur, which is loudest at the 
points mentioned, indicates — 

Stenosis of the right auriculo-ventricular open- 
ing. This also occurs but seldom, and is marked 
by the same symptoms as insufficiency. 

(7) A systolic murmur, which is heard loudest 
in the second left intercostal space, indicates — 

Stenosis of the mouth of the pulmonary artery, 
if it is very loud and perceptible to the touch, 
and if the cardiac dullness is increased toward 
the right. Stenosis and insufficiency of the pul- 
monary valves, as well as roughness upon them, 
are extremely rare. But accidental murmurs 
frequently arise in this region. 

(8) A diastolic murmur, which is loudest in the 
second intercostal space, indicates — 



128 AUSCULTATION OF CIRCULATORY ORGANS. 

Insufficiency of the pulmonary valves. In this 
case there is also hypertrophy of the right ven- 
tricle. 



Arterial Sounds. 



In normal conditions, sounds are heard only 
in those vessels lying near the heart. 

The diastolic tone is always heard, while the 
systolic is often wanting. Moreover, as on the 
heart, the latter is less loud than the diastolic. 
There is no normal tone in the crural artery, and 
likewise but little in the smaller arteries, such as 
the radial and tibial. The disappearance of the 
diastolic sound in the carotid and subclavian 
arteries, when the second sound is replaced by 
a murmur at the aortic valves, proves that the 
diastolic sound is transmitted from the heart 
and even from the aortic valves. The systolic 
sound may likewise be only a propagated tone; 
but it is probable that it is also produced at the 
same time by the arterial walls, for this reason, 
that during systole they pass from a low into a 
high degree of tension. 

A systolic tone is heard in the crural artery, 
and also in the smaller arteries, as the radial, 
volar arch, plantar, and metatarsal, (1) where 
there is insufficiency of the aortic valves; (2) in 
acute febrile diseases, unaccompanied by hyper- 



ARTERIAL SOUNDS. 129 

trophy of the left ventricle. In case of insuffi- 
ciency of the aortic valves we have a pulsus 
celer, — that is, the blood-wave is high and short. 
The blood-wave is rendered high by a large 
quantity of blood being forced out of the hyper- 
trophied left ventricle, the arteries having a low 
degree of tension. In this cardiac defect the 
tension of the aortic system is abnormally low, 
because the aortic blood during diastole flows 
out in two directions, — through the capillaries, 
and into the left ventricle. Then, when the 
arterial walls pass from the diminished diastolic 
tension to the high systolic, they give the sound. 
In disease accompanied by high fever the pulse 
is not only frequent, but often also rapid. The 
elevated temperature of the body causes a re- 
laxation of the smaller arterial walls, while in a 
lower temperature they contract. But relaxed 
arterial walls present less resistance to the empty- 
ing of the aortic system, since the tension of the 
latter in this case is also diminished. There is 
more force in the systolic contraction, and a high 
tension of the arterial walls is produced (a high 
blood-wave), hence in this case the arteries also 
yield a sound. In hypertrophy of the left ven- 
tricle, resulting from increased resistance in the 
peripheral arteries (arterial sclerosis), we have a 
slow pulse, pulsus tardus, a long and low wave, 
and increased tension in the aortic system ; hence 
the smaller arteries yield no sounds. The absence 

12 



130 AUSCULTATION OF CIRCULATORY ORGANS. 

of the systolic sound in the carotids has no diag- 
nostic value. 

An augmentation of the first sound in the 
carotid arteries has rarely been observed, result- 
ing from insufficiency of the aortic valves. 

Absence of the diastolic sound in the carotids 
proves that the aortic valves, which produced 
the second sound, are incapable of producing 
sound by vibration. But it does not follow that 
there is insufficiency. Insufficiency, however, 
may with certainty be inferred when the apex- 
impulse is augmented and heard beyond its 
normal sphere. 

The second sound of the carotids may also be 
wanting now and then in case of acute febrile 
diseases, because in such instances the tension 
of the aortic system is diminished. 

The second sound of the carotids appears aug- 
mented in those cases where the second aortic 
sound is augmented. 

Where there is insufficiency of the aortic 
valves, the diastolic murmur is seldom trans- 
mitted so far as the carotid arteries. 

A systolic murmur is likewise often heard in 
the carotids, as well as in the heart, in case of 
anaemia, chlorosis, and in many acute diseases. 
Where there is insufficiency of the aortic valves, 
there is often heard a deep murmuring sound, 
though no roughness may exist on the arterial 
wall. The diastolic regurgitation of blood from 



PHENOMENA IN ANEURISMS AND VEINS. 131 

the aorta into the left ventricle creates a lessened 
tension of the walls of the carotid arteries. 
These may become so relaxed thereby that in 
the high systolic tension they are able to pro- 
duce no normal sound, but only an irregular 
murmur. In case of the narrowing of the larger 
arteries, for example, through the presence of 
tumors, there may likewise arise a murmur ; 
and this is always so whenever the stethoscope 
is pressed too firmly. 



Auscultatory Phenomena in Aneurisms and Veins. 

Over aneurisms of the ascending aorta and of 
the aortic arch a double sound is usually heard, 
which in many cases is even louder than the 
double cardiac sound. The first sound is ap- 
parently produced by the systolic tension of the 
walls of the aneurism; the second sound is 
derived from the heart. The second sound is 
extremely seldom heard in an aneurism of the 
abdominal aorta, and then only when it is situ- 
ated close below the diaphragm. In aneurisms 
of superficial arteries the second sound is never 
heard. The systolic murmurs are not always 
heard in aneurisms ; when they appear they are 
usually transmitted from the heart, more seldom 
through irregular vibrations of the walls of the 



132 AUSCULTATION OF CIRCULATORY ORGANS. 

sac, or through compression produced by the 
pressure of adjacent organs or by that of the 
stethoscope. A diastolic murmur only appears 
in aneurisms which are situated near the heart, 
being transmitted from the heart. Consequently, 
an aneurism may exist unaccompanied by mur- 
murs of any kind. 

In the venous system only one acoustic phe- 
nomenon manifests itself, namely, the nun-mur- 
mur (bruit de diable), in the external jugular vein. 
It is a humming or singing continuous sound, 
which is augmented during systole, or it may 
appear in an interrupted manner. It is heard 
not only in anaemia and chlorosis, but also in 
quite healthy persons; hence it has no value in 
diagnosis. It is distinguished from arterial mur- 
murs by this, that there is no systolic and dias- 
tolic distinction of sound. Through pressure, 
however light, made above the stethoscope, it 
can be made to disappear, which is impossible 
in case of murmurs which originate in the heart. 
It must therefore be inferred that these murmurs 
arise in the veins themselves; but in what way 
they are produced is not known. 

The cat-purring sound (fremissement cataire) is 
nothing else than a loud murmur sensible to 
touch. When the finger is laid upon it, we feel 
a slight tremor, similar to the purring of a cat. 
This may be systolic and diastolic, like those 
murmurs to which it is related in respect to time 



PERICARDIAL MURMURS. 133 

and place. A systolic tremor on the apex of the 
heart appears in case of insufficiency and con- 
siderable roughness of the mitral valve. It may 
also be observed in very strongly augmented 
cardiac impulse, but certainly very seldom. Di- 
astolic or so-called presystolic tremor at the apex 
of the heart proves quite certainly stenosis of the 
left auriculo-ventricular opening. Systolic tre- 
mor at the upper end of the sternum, on a level 
with the third rib, indicates stenosis or roughness 
of the aortic valves ; but it may be caused by 
aneurism of the ascending aorta. Diastolic tre- 
mor in this region occurs in case of insufficiency 
of the aortic valves. In case of augmentation of 
the second sound of the pulmonary artery, a 
slight throbbing may be perceived against the 
finger in the second left intercostal space of which 
we have before spoken. A diffused tremor over 
the whole cardiac region authorizes us to infer 
structural change of several valves. 



Pericardial Murmurs. 

In pericarditis the pericardial friction-sounds, 
resulting from fibrinous deposit on the visceral 
layer of the pericardium, appear as in pleuritis. 

"When the fibrinous deposit is diffuse, the mur- 
mur is heard more extended; but usually the 

12* 



134 AUSCULTATION OF CIRCULATORY ORGANS. 

pericardial murmurs are only heard in circum- 
scribed places where they arise, because they are 
not, like the endocardial, transmitted by means 
of the current of blood. When loud, they may 
also be felt by the hand. Their timbre usually 
consists of a slight, rasping, friction al, or grating 
sound. By this they can also be distinguished 
from the endocardial murmurs. Still, a friction- 
sound may be so weak as to sound exactly like 
an endocardial blowing or respiratory sound. 
The cardiac sounds are usually distinct and clear, 
but they may be completely masked by a very 
loud murmur. The pericardial sound, as respects 
time, belongs neither to systole nor diastole; 
it usually manifests itself between the two, and 
therein consists the principal difference between 
pericardial and endocardial sounds. The cause 
of this is that the pericardial sounds are produced 
by the action of the heart, principally during its 
spiral motion, which outlasts systole as well as 
diastole. Two divisions of the sound can also 
usually be distinguished, one belonging more to 
the systolic, the other to the diastolic spiral mo- 
tion. It likewise appears to rise and fall, and 
resembles the double sound accompanying insuf- 
ficiency and roughness of the aortic valves or 
stenosis of the left arterial opening. The exact 
coincidence of the latter sound with systole and 
diastole, the site of its greatest augmentation 
being on the aortic valves, the augmented apex- 



PERICARDIAL MURMURS. 135 

impulse and the pulsus celer enable us to guard 
against confounding it with any other sound. 
However, a weak friction-sound may occur si- 
multaneously with systole or diastole, but that is 
very unusual. Then other symptoms must be 
brought to our aid, in order to enable us to dis- 
tinguish it from an endocardial sound. The 
pericardial sound is also further distinguished 
by change in timbre and place. It may in the 
course of a day or a few hours either increase 
or diminish, and entirely disappear, or change 
its place according to the nature and location of 
the fibrinous deposit. Endocardial murmurs 
also sometimes change their character and the 
place of their greatest intensity, but not in so 
short a time. A change of position in the patient 
has no influence upon the latter, while a peri- 
cardial sound often becomes louder when the 
patient sits up or lies upon one side, particularly 
the left ; or it appears in some other place, be- 
cause the heart always occupies the lowest part 
of the pericardium distended by fluid. 

A pleuritic friction-sound disappears when the 
patient holds his breath, but a pericardial friction- 
sound never does. Pericardial sounds become 
louder by pressing the stethoscope down firmly ; 
but when they are very loud no augmentation 
manifests itself in this way. Endocardial mur- 
murs may also thus be rendered louder in case 
the thoracic wall be yielding. 



136 AUSCULTATION OF CIRCULATORY ORGANS. 

Pleuritis on the left side may be transmitted 
to the parietal layer of the pericardium and pro- 
duce a friction-sound there. Now and then the 
latter also appears, dependent upon the respira- 
tory action of the thorax : if this is not the case, 
it is difficult to distinguish it from a sound of the 
visceral surface. In the first case there exist 
pleuritic friction, displacement of the heart, and 
other pleuritic symptoms; in the latter, aug- 
mented and increased cardiac dullness exist. 



APPENDIX. 



(13t) 



APPENDIX. 



The Doctrine of the Apex-Impulse. 

The site of the apex-impulse is of great im- 
portance in judging of the size and position of 
the heart ; it often throws light upon a case when 
auscultation and percussion by themselves alone 
leave us in doubt; hence we will here concisely 
discuss this subject. 

By the term " apex-impulse" is to be under- 
stood the systolic elevation which occurs in the 
fourth or fifth intercostal space between the linea 
parasternalis and the linea mammillaris. The 
apex-impulse must be distinguished from the 
cardiac impulse, since the latter includes all 
those movements which occur in the whole car- 
diac region during systole. 

Three different explanations have been given 
of the apex-impulse. 

(1) The Theory of Kiwisch. — Kiwisch first an- 
nounced the opinion that the apex-impulse arises 
from this : that the heart, which lies close to the 
thoracic wall, during systole becomes thicker, 
harder, and more arched, and the arched surface 

(139) 



140 THE DOCTRINE OF THE APEX-IMPULSE. 

presses into the intercostal spaces. The princi- 
pal objection to this theory lies in this, — that in 
cases of augmented and increased cardiac dull- 
ness, where a large part of the heart lies close 
to the thoracic wall, the elevation appears at 
the apex and nowhere else. Bamberger accepts 
this theory. 

(2) The lever-theory, first introduced by Hope, 
and afterward supported by Ludwig and Kursch- 
ner. During systole the heart rises toward the 
thoracic wall, while it turns around an imaginary 
transverse axis drawn through the base of the 
ventricle, in which the apex of the heart, as the 
most distant point, describes the largest arc. 
During diastole the heart falls back again toward 
the vertebral column. In systole the longitudi- 
nal axis of the heart forms almost a right angle 
with the base, while in diastole it forms an obtuse 
angle. This lever-action of the heart has, up to 
the present time, only been established on the 
open thorax. The lower part of the heart, under 
normal conditions, lies close to the thoracic wall. 
Against this theory Scoda has raised the weighty 
objection that when the apex-impulse appears at 
the same time in two intercostal spaces it is 
always perceived first in the upper space. If it 
had its origin in the lever-motion, then, on the 
contrary, it ought to be perceived first in the 
lower intercostal space. 

(3) The rebounding theory, introduced by Gut- 



THEORY OF ORIGIN OF APEX-IMPULSE. 141 

brocl and Scoda, and followed by Traube. It is 
based upon the following physical fact. If a vessel 
filled with gas or fluid be freely suspended in the 
air, then the gas or fluid exerts a constant uni- 
form pressure on the walls of the vessel. If the 
fluid be allowed to flow out through an opening, 
then the uniformity of the pressure is disturbed. 
At the opening where the fluid flows out there 
is no longer any pressure, while on the opposite 
wall the primary pressure still remains. The 
consequence is that the vessel moves toward the 
side opposite to the opening. This is the so-called 
rebounding movement, which occasions the back- 
ward action in all kinds of fire-arms, and sets the 
water-wheel of Segner in motion. In systole of 
the heart, blood flows out of the left ventricle into 
the aorta, out of the right into the pulmonary ar- 
tery. Thus no pressure exists at the arterial 
mouths, and the ventricle inclines to move toward 
the side opposite to the blood's point of exit. 
The resultant of these two forces, acting in oppo- 
site directions, falls upon the left ventricle and 
the apex. The cone of the ventricle and the 
apex of the heart, under the influence of this law, 
make a rotary motion during systole around its 
longitudinal axis from the right side above, 
downward toward the left side. In many healthy 
persons the site of the apex-impulse can be seen 
quite distinctly describing a waved line from the 
right to the left. Since a lengthening of the 

13 



142 THE DOCTRINE OF THE APEX-IMPULSE. 

cone of the ventricle, which might explain this 
fact, does not take place in systole, but, on the 
contrary, a shortening of it, there must of course 
be a movement from the right to the left. 

The rebounding theory has indeed many oppo- 
nents at present, but it is the only one which 
readily explains all the phenomena of the apex- 
impulse. 



The Deviations of the Apex-Impulse. 

(1) In Regard to its Position. — In the normal struc- 
ture of the thorax the apex-impulse appears in 
the fourth or fifth intercostal space, between the 
linea parasternalis and the linea mammillaris, 
but a little nearer the latter, never below the 
sixth, nor above the fourth, rib. Outwardly it 
does not extend beyond the linea mammillaris, 
nor inwardly beyond the linea parasternalis. 
Abnormally the apex-impulse may appear above 
the fifth rib, and at the same time lie outside of 
the linea mammillaris. The cause may be, an 
abnormally high position of the diaphragm. In 
case of considerable distention of the abdomen 
from ascites, meteorism, and even from preg- 
nancy, the diaphragm is pressed upward, and in 
case of puerperal peritonitis the apex-impulse 
may correspond to the third rib. By this means 
the heart is raised, and at the same time turned 



THE DEVIATIONS OF THE APEX-IMPULSE. 143 

on its base, so that the longitudinal axis assumes 
a horizontal position, and therefore of course the 
apex falls farther outward. If there be no dis- 
tention of the abdomen, then there probably 
exists cardiac hypertrophy. 

The occurrence of the apex-impulse below the 
fifth rib and beyond the linea mammillaris is very 
significant. In this case it often has but little 
height and breadth, so that palpation must be 
very exact in order to determine it. It may even 
lie in the seventh intercostal space, and tempo- 
rarily reach the linea axillaris. 

The apex-impulse appears above the fifth rib, 
and very near the linea mammillaris in case of 
contraction and induration of the left lung in 
connection with vicarious enlargement of the 
right lung. Since the left lung contains no air, 
there is a less than normal pressure on the dia- 
phragm ; hence the left part of the latter, to- 
gether with the heart, is forced upward by the 
pressure in the abdomen, which is equal to one 
atmosphere. The patient in such cases offers but 
little evidence of disease. The appearance of 
the apex-impulse below the fifth rib, with syn- 
chronous deviation outwardly from the linea mam- 
millaris, may arise from displacement of the heart 
and a low position of the diaphragm. This occurs 
in case of enlargement of the right pleural cavity 
from pneumothorax, or from extensive pleuritic 
exudation. From this arise compression of the 



144 TEE DOCTRINE OF TEE APEX-IMPULSE. 

lungs and a low position of the diaphragm, both 
easy to be ascertained by means of percussion, 
and then the apex-impulse appears beneath the 
fifth rib and beyond the linea mammillaris. If 
pneumothorax, pleuritic exudation on the right 
side, and a low position of the diaphragm do not 
exist, then this change in position of the apex- 
impulse authorizes the inference of enlargement 
of the heart. Still, pericardial exudation, aneu- 
rism of the ascending aorta, and mediastinal 
tumors may cause the deviation of the apex-im- 
pulse in the last-named manner. 

Simple doicnward falling of the apex-impulse 
below the fifth rib may be brought about by 
displacement of the heart in a direction from 
above downward. This displacement seldom 
occurs alone, but is usually combined with a de- 
viation outwardly. A falling of the diaphragm 
and heart occurs particularly in case of pulmo- 
nary emphysema. The position of the heart is 
then almost horizontal, while the base falls to- 
ward the epigastrium, and the apex lies in the 
sixth or seventh intercostal space, almost covered 
by the lungs. Aneurism of the ascending aorta 
and chronic pericardial exudation of long stand- 
ing may likewise cause a simple falling of the 
apex-impulse. In most of these cases it also lies 
at the same time a little more to the left. With 
the exception of the above-named cases, simple 
falling of the apex-impulse authorizes the infer- 



BREADTH OF THE APEX-IMPULSE. 145 

ence of an elongation of the heart. In case of 
pleuritic exudation on the left side, or in pneumo- 
thorax, the apex-impulse deviates in an inward 
direction. In these cases the heart is simply 
pushed farther to the right, without any change 
in its position. It has the same position before 
its displacement as afterward. 

In case of chronic tuberculosis, also, the apex- 
impulse may appear a little farther inward. In 
this disease there is diminution in the quantity 
of blood, consequently atrophy of all tissues, in- 
cluding the cardiac muscle, so that the apex- 
impulse is removed farther inward. If this con- 
dition ceases, then hypertrophy of the right 
ventricle may follow as the result of increased 
obstruction to the circulation in the lungs. 



Breadth of the Apex-Impulse. 

Normally the apex-impulse can be covered by 
the ends of two fingers; its greatest breadth is 
at the most one inch. It attains a greater com- 
pass, so that it is even perceptible to the sight 
and touch in two intercostal spaces, in case of a 
considerable enlargement of the left ventricle 
with hypertrophy, as is evident in insufficiency 
of the aortic valves. The apex-impulse also 
assumes in this case a greater elevation ; if this 
be not the case, then there is a complication 

13* 



146 THE DOCTRINE OF THE APEX-IMPULSE. 

which counteracts the elevation, such as an ad- 
hesion of the pericardium to the heart. 

A systolic elevation of the whole left ventricle 
indicates a high degree of hypertrophy and dila- 
tation of the left ventricle. 

In case of hypertrophy and dilatation of the 
right ventricle there is neither augmentation nor 
increase in compass of the apex-impulse, but 
occasionally even the opposite, although in this 
case the apex of the heart is partly made by the 
right ventricle. 

In many cases of stenosis of the left auriculo- 
ventricular opening, in connection with consider- 
able hypertrophy of the right ventricle, the apex- 
impulse cannot be perceived. Also in case of 
stenosis of the aortic mouth, there is often no 
apex-impulse perceptible, or only a very small 
one, notwithstanding hypertrophy and dilatation 
of the left ventricle. 

The height of the apex-impulse may also vary, 
but we have no measure for these variations. 
Very considerable changes may be judged of by 
palpation; for example, in case of insufficiency 
of the aortic valves the elevation is very high ; 
but in case of stenosis of the left auriculo-ven- 
tricular opening it is very slight. 

Much more important are the variations in 
resistance. This is tested by the greater or less 
pressure which must be exerted by the fingers 
in order to prevent the occurrence of the apex- 



BREADTH OF THE APEX-IMPULSE. 147 

impulse. Very various degrees of force are 
necessary for this, and sometimes it is impossible 
to repress it. 

In this manner, as already mentioned, the re- 
sistance, that is, the tension of the arteries, may 
be tested. A high degree of resistance occurs 
in hypertrophy of the left ventricle, and from 
this, when long continued, as well as from in- 
creased resistance of the apex, hypertrophy of 
the left ventricle can be inferred with certainty. 
A slight degree of augmentation of the apex- 
impulse occurs temporarily in all acute febrile 
diseases, especially in endocarditis and pericar- 
ditis, and also in various convulsive affections, 
particularly in case of epilepsy, hysteria, and 
tetanus. 

Feebleness or disappearance of the apex-im- 
pulse also occurs under normal conditions, so 
that they have no significance except in connec- 
tion with other symptoms. 

The disappearance of the apex-impulse is im- 
portant in the diagnosis of extensive pericardial 
exudation. For instance, if there is an abnor- 
mally extensive cardiac dullness, and no trace of 
the apex-impulse within its limits, then it is safe 
to infer exudation in the pericardium. Enlarge- 
ment of the volume of the heart cannot have 
produced this increased cardiac dullness, for 
otherwise a distinct apex-impulse would be 
present. 

Other causes for diminution in the force of the 



148 THE DOCTRINE OF THE APEX-IMPULSE. 

apex-impulse are, moderate pleuritic exudation 
on the left side, and adhesion of the pericardium 
with the heart. Still, in the latter case the apex- 
impulse may even be strengthened, if at the 
same time there is a considerable hypertrophy 
of the left ventricle. Atrophy or fatty degenera- 
tion of the muscular structure of the heart, di- 
minished innervation (as in general weakness, 
syncope, and apoplexy), dilatation, with thinness 
of the walls of the heart, increase in the volume 
of the lungs (emphysema), thickening of the 
thoracic walls by excessive fatty deposit, and 
oedema, are also causes of diminution of the 
apex-impulse. 

During systole there appears now and then a 
double or triple apex-impulse, to which nothing 
but an arterial pulsation corresponds. In con- 
nection with this the systolic sound may like- 
wise appear doubled or tripled. This phenome- 
non is probably the result of an irregular or 
impulsive contraction of the ventricles. In case 
of a very weak contraction of the heart, or in 
considerable stenosis of the aortic mouth, the 
heart-stroke may be more frequent than that of 
the pulse, because the blood, which is forced 
from the heart by each contraction, cannot cor- 
respondingly produce a perceptible distention of 
the arteries. 

Occasionally the elevation of the apex-impulse 
is not felt during systole, but during diastole. 
This phenomenon only occurs when the peri- 



DEVIATIONS OF THE APEX-IMPULSE. 149 

cardium and heart have become adherent, by 
which the rotation of the ventricular cone from 
above on the right toward the left downward, 
becomes impossible during systole. 

Finally, there also occur systolic movements 
in the cardiac region, which have nothing to do 
with the apex-impulse. Under this head are the 
following cases : 

The systolic elevation of the sternum and of the 
adjacent costal cartilages, in which the apex-im- 
pulse may be present or absent. This phenome- 
non is a certain indication of dilatation of the 
right ventricle, which is not necessarily accom- 
panied by hypertrophy. Thus, a systolic eleva- 
tion in the area of the left ventricle only author- 
izes an inference of dilatation, not of dilatation 
and hypertrophy. Simple dilatation alone creates 
a systolic elevation in the area of the affected 
ventricle. 

A systolic elevation in the second intercostal 
space, or, if the position of the heart be low, in 
the third, occurs in displacement of the heart 
resulting from contraction of the left lung, be- 
cause in this case the pulmonary artery lies close 
to the thoracic wall. 

A systolic elevation of the left half of the epi- 
gastrium (at the left of the linea alba), pulsatio 
epigastrica, epigastric pulsation, only occurs in 
a low position of the diaphragm, and generally, 
but not necessarily, proceeds from enlargement 
of the volume of the heart. In normal concli- 



150 THE DOCTRINE OF THE APEX-IMPULSE. 

tions it occurs only in persons with short chests ; 
further, in case of hypertrophy of the left lobe of 
the liver, or tumors in the scrobiculus cordis, 
most distinctly when at the same time there is 
hypertrophy or increased cardiac activity. The 
epigastric pulsation occurs in a few instances 
originating from that vertical position of the 
heart which accompanies pleuritic exudation 
upon the left side, and pneumothorax. Other- 
wise the apex-impulse is felt at the left of the 
pulsating point of the epigastrium. The epi- 
gastric pulsation may also proceed from the 
abdominal aorta, which in this case is either 
normally or aneurismally dilated. It often ap- 
pears where the abdominal wall is relaxed and 
emaciated, and then the pulsating aorta can gener- 
ally be distinctly felt through the wall. Increased 
force of the action of the heart, whether from 
nervous excitement, hypertrophy, fever, or ob- 
structed circulation in the lower part of the 
aorta, — for example, through pressure (forward 
curvature of this part of the vertebral column 
and tumors resting on the aorta), — can also cause 
epigastric pulsation. That the pulsation pro- 
ceeds from the aorta, is often perceived by 
means of palpation, and furthermore by its oc- 
curring a little after the first cardiac sound, or 
the apex-impulse; and likewise from the fact 
that only the systolic sound of the aorta, or a 
systolic murmur, can be heard, because the 
second sound is not transmitted so far. If the 



SYSTOLIC MOVEMENTS IN CARDIAC REGION 151 

epigastric pulsation be produced by the heart, 
then it coincides exactly with systole, and the 
carotid pulse occurs a little after; and, further, 
the first and second sounds of the heart are 
heard at the point of pulsation. 

Instead of the systolic elevation at the lower 
part of the sternum and epigastrium, merely a 
simple vibratory trill may also be perceived by 
palpation. When the first sound is much aug- 
mented over the left ventricle, a vibratory trill 
in the cardiac region may in most cases be per- 
ceived. The absence of the systolic elevation, as 
well as of the vibratory trill, in the cardiac 
region, occurs in normal conditions in case of 
atrophy of the heart and increased volume of 
the lungs, in which only a very small part of the 
heart remains uncovered by them. The absence 
of the apex-impulse is of importance only in case 
of pericardial exudation, as has been already 
mentioned. 

As before said, the ventricular cone, in systole, 
rotates from above on the right toward the left, 
downward. If this movement is strong, as in 
case of hypertrophy of the left ventricle, then it 
may occur that the heart, during systole, may lie 
a whole intercostal space lower and farther to 
the left. In persons with thin thoracic walls, 
during each systole a sinking inward may be 
seen of the third or fourth intercostal space near 
the sternum ; that is, at the point whence the 
heart moves in its systolic locomotion there 



152 THE DOCTRINE OF THE APEX-IMPULSE. 

arises a vacuum, and the pressure of the atmos- 
pheric air causes there an incurvation of the 
thoracic wall. Such incurvation has no impor- 
tance. 

But an incurvation which is limited to the 
apex of the heart is of diagnostic value. That 
this is the case may be ascertained by means of 
careful percussion. If this reveals the normal 
area of cardiac dullness, then from the incurva- 
tion of the apex it is safe to infer an adhesion 
of the pericardium and heart. 

If in every systole not merely the intercostal 
spaces of the greater part of the cardiac region 
sink in, but also the ribs, then this adhesion is 
of great extent. 

A diastolic pulsation in the second or third 
intercostal space at the left of the sternum, 
accompanies augmentation of the second sound 
of the pulmonary artery. How this can be used 
to determine displacement of the heart — for ex- 
ample, in contraction of the left lung — has been 
already mentioned. Here it may yet be men- 
tioned that this, together with the apex-impulse, 
gives the length and direction of the longitudinal 
axis of the heart. The place of the diastolic 
pulsation corresponds to the commencement of 
the pulmonary artery or to the basis of the heart, 
while the apex-impulse corresponds to the apex. 
A straight line drawn between the two thus gives 
the direction of the longitudinal axis of the heart, 
and the length of the heart. 















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